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ADENOMYOMA 



OF THE 



UTERUS 



BY 



THOMAS STEPHEN CULLEN 



\ \ ' /, 



ASSOCIATE PROFESSOR OF GYNECOLOGY IN THE JOHNS HOPKINS UNIVERSITY 
ASSOCIATE IN GYNECOLOGY IN THE JOHNS HOPKINS HOSPITAL 



■^ / 



ILLUSTRATED 

BY 
HERMANN BECKER and AUGUST HORN 



JS IH-^^ 




PHILADELPHIA AND LONDON 

W. B. SAUNDERS COMPANY 

.1908 



Copyright, 1908, by W. B. Saunders Company 



PRINTED IN AMERICA 

PRESS OF 

3. SAUNDERS COMPANY 
PHII-ADE t-PHIA 



TO THE MEMORY OF 
MY FATHER 

€^l)e HeijerenU ^bomas Cullrn 

WHO WAS BORN IN THE COUNTY OF FERMANAGH, IRELAND, 
IN 1836,, AND DIED IN LONDON, CANADA, 'iN 1895, 

THIS BOOK 

IS AFFECTIONATELY DEDICATED 



PREFACE 



One afternoon in October, 1894, while makin<>; the routine 
examination of the material from the operating- room I found a 
uniformly enlarged uterus about four times the natural size. On 
opening it I found that the increase in size was due to a diifuse 
thickening of the anterior wall. Professor William H. Welch, 
when consulted, said that the condition was evidently a most un- 
usual one and suggested that sections be made from the entire 
thickness of the uterine wall. Examination of these sections showed 
that the increase in thickness was due to the presence of a diffuse 
myomatous tumor occupying the inner portion of the uterine wall, 
and that the uterine mucosa was at many points flowing into the 
diffuse myomatous tissue. A few months later a second adeno- 
myoma was met with. Both of these cases were reported at the 
Johns Hopkins Hospital Medical Society in March, 1895, and pub- 
lished in the Johns Hopkins Hospital Reports, Vol. 6, 1896. 

Since that time we have carefully inspected all our material 
for adenomyoma and have encountered over ninety adenomyomata 
of various kinds in the uterus. 

Our material has been obtained chiefl}^ from the Gynecolog- 
ical Department of the Johns Hopkins Hospital, from Dr. Kelly's 
private sanatarium and from my cases at the Church Home and 
Infirmary and elsewhere. The exact source in each case is given 
in the tables of cases at the end of the book, from which also the 
reader can find at a glance the page number of any gynecological 
or pathological number mentioned in the book. 

After the pul^lication of von Recklinghausen's work on Adeno- 
myoma in 1896 considerable controversy arose as to the origin 



VI PREFACE / 

of the gland elements in adenomyomata. Our first cases had 
clearly shown that the glands in the diffuse myoma owed their 
origin to a flowing outward of the normal uterine mucosa. In 
all subsequent cases these tumors were examined most carefully 
from this standpoint. Sometimes the mucous membrane origin 
was easily proved, but in many cases not only were numerous 
sections necessar}% but in some instances a clear idea of the con- 
dition was obtainable only after an examination of very large sec- 
tions embracing the entire uterine wall. This labor yielded fruit, 
as in nearly every case in which diffuse adenomyoma existed we 
have been able to trace the mucous membrane origin of the glands. 
Much credit for the large and beautiful sections is due to our labora- 
tor}^ assistant, Mr. Benjamin 0. McCleary. 

While endeavoring to ascertain the method of development 
of adenomyomata I have likewise been trying to determine how 
these growths can be recognized clinically. I cannot help feeling 
that any one who reads the chapter on symptoms will agree with 
us that diffuse adenomyoma has a fairly definite clinical history 
of its own and that in the majority of cases it can be diagnosed 
with a relative degree of certainty. This definite gain in our know- 
ledge certainly emphasizes the fact that any morbid process should 
be studied carefully both from its histological and also from its 
clinical aspects and shows the importance, for all those who do 
surgical work, of a thorough familiarity with the histological appear- 
ances of the pathological processes they are dealing with. 

In this book the publishers have deemed it wise to use a larger 
type than usual. At the beginning of each case an epitome is 
given and in the succeeding paragraphs the essential features are 
emphasized by the employment of spaced type. This arrangement 
will permit those who wish to obtain the gist of the book to do 
so in a few hours, without going into all the minor details, provided 
that their reading is supplemented by a careful study of the illus- 
trations. 

I wish to express my thanks, to Dr. Henr}^ M. Hurd for his ad- 
vice on numerous occasions, to my brother. Dr. Ernest K. CuUen, 



PREFACE Vll 

for the manifold details he has looked after for me, and to Miss 
Cora Reik, my secretary, for the continued interest she has taken 
in the preparation of this volume. 

I am under especial obligation to Dr. Frank R. Smith for his 
revision of the manuscript, and for correcting the proof-sheets. 

To my friends Mr. Hermann Becker and Mr. August Horn I 
am deeply indebted for their excellent and faithful illustrations. 

With the publishers, W. B. Saunders Company, my relations 
have been most cordial and I am especially mindful of the many 
kindnesses shown by Mr. R. W. Greene, one of the vice-presidents 
of the company. 

Thomas S. Cullen. 

Baltimore, May L 1908. 



CONTENTS 



Chapter I p^,.,.. 

Adenomyoma of the Uterus 1 

Chapter II 
Cases of Adenomyoma in ^VHICH the Uterus Retains a Relatively Normal 
Contour 29 

Chapter III 
Cases of Adenomyoma in which the Uterus Retains a Relatively Normal 

Contour 52 

Chapter IV 
Cases of Adenomyoma in which the Uterus Retains a Relatively Normal 

Contour 88 

Chapter V 
Subperitoneal and Intraligamentary Adenomyomata 125 

Chapter VI 
Submucous Adenomyomata 156 

Chapter VII 
Cervical Adenomyomata 165 

Chapter VIII 
Condition of the Tubes and Ovaries when Adenomyoma of the Uti:rus 

Exists 171 

Chapter IX 
The Clinical Picture in Cases of Adenomyoma of the Uterus 173 

Chapter X 
Differential Diagnosis IN Cases of Adenomyoma of the Uterus 177 

Chapter XI 
Treatment of Adenomyomata of the Uterus 186 

Chaptj:r XII 

Prognosis in Cases of Adenomyoma of the Uterus 187 

ix 



X CONTENTS 

Chapter XIII p^ge 

Origin of Adenomyomata of the Uterus 193 

Chapter XIV 
Causes of Adenomyoma of the Uterus 199 

Chapter XV 
Hy^pertrophy of the Cervix and Diffuse Adenomyoma of the Body of the 

Uterus 200 

Chapter XVI 
Adenomyoma in one Horn of a Bicornate Uterus 203 

Chapter XVII 
Diffuse Adenomyoma of the Body of the Uterus Occurring in Cases of 

Squamous-cell Carcinoma of the Cervix 206 

Chapter XVIII 
Adenocarcinoma and Adenomyoma Occurring Independently in the Body" 

of the Same Uterus 218 

Chapter XIX 
Adenocarcinoma of the Body of the Uterus Developing from an Adeno- 
myoma 222 

Chapter XX 
A Multiplicity of Pathological Changes in the Pelvis 228 

Chapter XXI 
Diffuse Myomatous Thickening of the Uterus but no Glandular Inva- 
sion 230 

Chapter XXII 
Adenomyoma of the Uterine Horn 235 

Chapter XXIII 
Pregnancy in the Left Fallopian Tube; Discrete Uterine Myomata; 
Diffuse Adenomyoma in the Right Uterine Horn with the Develop- 
ment of Decidual Cells around the Glands in the Adenomyoma 246 

Chapter XXIV 
Adenomyoma of the Round Ligament 250 

Summary 260 

Index of Cases Arranged According to their Gynecological Numbers. . . 263 

Index of Gynecological-Pathological Numbers 265 

Index 267 



LIST OF ILLUSTRATIONS 



FIG. PAGE 

1. Diffuse Adenomyoma of the Posterior Wall of the Uterus 10 

2. Diffuse Adenomyoma of the Posterior Uterine Wall 12 

3. Diffuse Adenomyoma of the Posterior Uterine Wall 19 

4. Diffuse Adenomyomatous Thickening in the Fundus and Posterior 

Uterine Wall with Extension en masse of the Mucosa into a 

Large Crevice between Myomatous Masses 26 

5. Diffuse Adenomyoma Forming a Complete Zone around the Uterine 

Cavity 35 

6. Diffuse Adenomyoma of the Uterine Wall with ^Iarked Extension 

OF THE Mucosa into the Growth - 37 

7. Extension of the Mucosa into a Diffuse Myoma of the Uterus 38 

8. Diffuse Adenomyoma of the Anterior Uterine Wall 42 

9. Diffuse Adenomyoma of the Anterior Uterine Wall 43 

10. Mode of Extension of Uterine Glands into a Diffuse Adenomyoma .... 44 

11. Diffuse Adenomyoma OF THE Uterus WITH Several Discrete Myomata. . 48 

12. Diffuse Adenomyoma of the Posterior Uterine Wall 49 

13. Diffuse Adenomyoma of the Uterus Involving the Antp^rior and 

Posterior Walls and Fundus 55 

14. Diffuse Adenomyoma of the Anterior and Posterior Uterine Walls . . 56 

15. Method of Penetration of the Mucosa in a Diffuse Adenomyoma of 

THE Uterine Wall 57 

16. Extension of Uterine Glands into the Diffuse Myomatous Tissue of 

AN Adenomyoma 59 

17. Interstitial and Subperitoneal Utp:rine ^Iyomata. Interstitial 

Adenomyoma 65 

18. Small Adenomyoma of the Fundus of the Uterus 66 

19. Diffuse Adenomyoma of the Uterus 69 

20. Diffuse Adenomyoma of the Uterine Wall 70 

21. Cyst-like Spaces Just Beneath the Peritoneum in Diffuse Adeno- 

myoma OF THE Uterus 72 

22. The Mucosa Lining One of the Cyst-like Spaces Situated Just Beneath 

THE Peritoneum in a Diffuse Adenomyoma of the Uterus 74 

23. Diffuse Adenomyoma of the Anterior Utp:rine Wall 77 

24. Diffuse Adenomyoma of the Anterior Uterine Wall 78 

25. Cross-section of a Gland Taken from Fig. 24 at d 80 

26. A Branching Gland from a Glandular Area in an Adenomyoma 81 

27. Diffuse Adenomyoma of the Body of the Utf:rus 90 

28. Extension of the Mucosa into the Muscle in a Case of Diffuse Adeno- 

myoma OF the Uterus 91 

xi 



Xll LIST OF ILLUSTRATIONS 

FIG. PAGE 

29. Method of Penetr.\tion of .\ Single Uterine Gland into the Diffuse 

Myomatous Growth of an Adenomyoma 92 

30. Diffuse Adenomyoma of the Body of the Uterus 96 

31. Discrete Uterine Myomata. Diffuse Adenomyoma with the Glands 

Originating from the Mucosa. Adenomy'Oma of the Left Uter- 
ine Horn 101 

32. Longitudinal Section of Discrete Myomata; Discrete Adenomyoma 

Ne.\r the Left Uterine Horn 102 

33. Subperitoneal, Interstitial and Submucous Uterine Myomata; Dif- 

fuse Adenomyoma of the Entire Fundus 107 

34. Discrete Myoma of the Cervix; Diffuse Adenomyoma of the Body of 

the LTterus Ill 

35. Diffuse Adenomyoma of the Body of the LTterus 116 

36. Diffuse Adenomyoma of the Fundus with Cystic Spaces in the Left 

Uterine Horn 120 

37. A Cystic Subperitoneal Adenomyoma of the Uterus 130 

38. A Cystic Subperitoneal Adenomyoma of the LTterus 131 

39. A Subperitoneal Cystic Adenomyoma Occurring in the Case of a Large 

Myomatous Uterus 134 

40. Cystic Subperitoneal Adenomyoma of the Uterus 136 

41. Subperitoneal and Interstitial L^terine Myomata. Adenomyoma of 

the Body of the Uterus. Adenomyoma Springing from the Left 
LTtero-ovarian Ligament 142 

42. Cross-section Through a Pedunculated Subperitoneal Adenomy^oma . . 1 44 

43. An Intraligamentary and also Partly Submucous Cystic Adenomyoma 

of the Uterus 151 

44. A Cystic Intraligamentary and Partly Submucous Adenomy'Oma of 

the Uterus 152 

45. The Submucous Portion of a Cystic Adenomyoma of the Uterus 154 

46. Submucous Adenomyoma of the LTterus 159 

47. Submucous Adenomyoma of the Uterus, the Myomatous Muscle Being 

Riddled with Miniature Uterine Cavities 162 

48. Interstitial Uterine Myomata with a Small Diffuse Adenomy'oma in 

THE Cervix 168 

49. Adenomyoma in the Outer Portion of the Cervix Near the Broad 

Ligament Attachment : . . . 169 

50. A Cystic Myoma Macroscopically Simulating a Cystic Adenomyoma .... 176 

51. A Small Uterine Polyp 178 

52. L.\rge Venous Sinuses in the Uterine Mucosa Causing Severe Hem- 

orrhages 179 

53. Thickening of the L^erine Mucosa. Marked Dilat.\tion of Some of 

THE Glands without any Atrophy of their Epithelium; very 
Dense Stroma 181 

54. A Portion of a Diffuse Adenomyoma of the Posterior Wall of the 

Uterus 188 

55. Diffuse Adenomyoma 189 



LIST OF ILLUSTRATIONS XIU 

FIG. PAGE 

56. Very Extensive Hypertrophy of the Cervix. Discrp:te Myoma and 

Diffuse Adenomyoma of the Body of the Uterus 200 

57. Adenomyoma in one Horn of a Bicornate Uterus 204 

58. Diffuse Adenomyoma in the Body of the Uterus 207 

59. Squamous-cell Carcinoma of the Cervix; Discrete Subperitoneal 

AND Interstitial Myomata; Diffuse Adenomyoma of the Pos- 
terior Uterine Wall 209 

60. Commencing Diffuse Adenomyoma of the Body of the Uterus Asso- 

ciated WITH Advanced Squamous-cell Carcinoma of the Cervix . . . 215 
6L Adenocarcinoma of the Body of the Uterus Associated with a Small 

Subperitoneal Adenomyoma 219 

62. Adenocarcinoma Developing from a Dilated Gland in an Adp:no- 

MYOMA of the Uterus 224 

63. Myoma, Adenomyoma and Primary Adenocarcinoma of the Body of the 

Uterus; Pyosalpinx and Primary Adenocarcinoma of the Ovary. . 228 

64. Adenomyoma of the Uterine Horn. 237 

65. Adenomyomata of Both Uterine Horns; Discrete Myomata; Diffuse 

Adenomyoma of the Uterus 243 

66. Left Tubal Pregnancy; Discrete Uterine Myomata; Adenomyoma 

of the Right Uterine Horn with Decidual Formation in the 
Stroma Surrounding the Glands 247 

67. Adenomyoma of the Round Ligament 256 

68. Adenomyoma of the Round Ligament 257 



ADENOMYOMA OF THE UTERUS 



CHAPTER I 
ADENOMYOMA OF THE UTERUS 

In 1903, in a review of the literature published in a supplement 
to Orth's Festschrift, I reported 22 cases of adenomyoma examined 
by me up to that date/ Since then I have paid especial attention 
to these growths and have been astonished at the striking frequency 
with which they occur. Out of a total of 1283 cases of myoma 
examined from April 1, 1893, until July 1, 1906, 73^ — that is, about 
5.7 per cent. — -were instances of adenomyoma.^ I have included 
only interstitial, subperitoneal and submucous adenomyomata and 
large adenomyomata of the uterine horns. The smaller nodules 
so frequently present in the cornua have been purposely omitted. 

Glandular elements have from time to time been noted in myo- 
mata, and according to Breus,* Schroeder, Herr and Grosskopf had 
been able to collect a total of one hundred cases up to 1884. But 
not until the appearance of the masterly work of von Reckling- 

^ Cullen, Thomas S. : Adeno-Myoma des Uterus, A'erlag von August Hirsch- 
wald, Berlin, 1903. 

^The following adenomyoma cases have been operated upon between July 1st, 
1906, and Dec. 31st, 1907: Path. Nos. 10,109, 10,499, 10,560, 10,596, 10,617, 10,669, 
10,677 (Gyn. 13,423), 10,767, 10,844 (Gyn. 13,590), 10,972, 11,078 (Gyn. 13,679), 11,120, 
11,149,11,191,11,195, 11,849, 11,859, 11,863, 12,007, makinga total of 19cases; showing 
beyond peradventure that this disease is particularly prevalent. We have had in 
all 92 cases of adenomyoma. 

^ In some of the cases no microscopic examination was made. To positively 
exclude the presence of adenomyoma it would have been necessary to take sections 
from many parts of the uterine wall. This would have entailed an enormous ex- 
penditure of labor that was often impossible. It will thus be seen that a certain 
number of cases of adenomyoma have probably been overlooked. 

* Breus, Carl: Ueber Avahre epithelfiihrende Cystenbildung in Uterus-Myomen. 
Leipzig und Wien, 1894. 

1 



2 ADENOMYOMA OF THE UTERUS. 

hausen/ published in 1896, had this subject received much atten- 
tion.' These growths, as their name impHes, consist of gland ele- 
ments and myomatous tissue. They form a distinct class of their 
own, and on microscopic examination their recognition is easy. 
Even in the gross specimens it is often possible to render a positive 
diagnosis. 

For the use of clinicians we divided these growths into three 
classes, although it will be readily seen that one class may merge 
imperceptibly into the other. The divisions are : 

(1) Adenom3"omata, the uterus preserving a relativel}^^ normal 
contour. 

(2) Subperitoneal or intraligamentary adenomj^omata. 

(3) Submucous adenomyomata. 

ADENOMYOMA IN WHICH THE UTERUS PRESERVES A RELATIVELY NORMAL 

CONTOUR 

The uterus may be nearly normal in size, as in Fig. 5 (p. 35), 
or it may be two or three times the natural size, as noted in Fig. 13 
(p. 55) and in Fig. 23 (p. 77). When the organ is considerably en- 
larged, it is frequently partly covered with adhesions. In these 
uteri there is a myomatous transformation of the muscle; the 
thickening extends from the mucosa outward, sometimes involving 
the wall in half its thickness, or at other times reaching even as far 
as the peritoneum (Fig. 13, p. 55). Sometimes it is limited to the 
anterior or posterior wall (Fig. 1, p. 10, and Fig. 23, p. 77), but may 

^ ^^on Recklinghausen, Friedrich: Die Adenomyome und Cystadenome der 
Uterus und Tubenwandung, ihre Abkunft von Resten des Wolff'schen Korpers. 
Berlin, 1896. (I wish to express my deep sense of obligation to Professor v. Reck- 
linghausen for his kindness in examining sections from several of the cases and for 
his valuable criticism of the same.) 

^ Probably the best article written in this country on adenomyoma of the uterus 
was that by Dr. J. M. Baldy and Dr. W. T. Longcope, presented to the Philadelphia 
Obstetrical Society and published in the American Journal of Obstetrics, 1902, 
vol. xlv, p. 788. 

^ I use the word "relatively" because if operative interference be long delayed 
some of the discrete myomata so frequently found may assume large proportions and 
almost completeh^ overshadow the adenomyoma, while at the same time greatly 
altering the contour of the uterus. 



DIFFUSE ADENOMYOMA OF THE UTERUS 6 

involve both (Fig. 5, p. 35). Where such is the case, we have a 
uterine cavity hned with a mucosa which is surrounded by a thick 
zone of myomatous muscle and covered externally with a mantle of 
normal muscle of variable thickness. The myomatous thickening 
is diffuse in character, consists of bundles of fibres running in all 
directions and along the advancing margin gradually merging into 
the normal muscle, in contradistinction to the condition found in 
simple myomata, which are sharply circumscribed. Given such 
thickenings of the uterine wall, we may always suspect the presence 
of gland elements. 

On examining the uterine cavity it is usually found that the 
mucosa at one or more points extends into the diffuse myomatous 
tissue beneath (Fig. 1, p. 10). This point is more readily verified 
by examining with a loup, when a careful scrutiny of the diffuse 
myomatous growth will discover small, round, irregular, triangular 
or oblong areas, composed of a waxy, fairly homogeneous tissue, 
lying between myomatous bundles. These areas correspond closely 
in appearance with the uterine mucosa, and with the glass one can 
make out punctiform openings, which are cross-sections of glands. 
Frequently such areas contain cyst-like spaces varying from .5 
to 5 mm. or more in diameter (Fig. 5, p. 35, Fig. 19, p. 69). Other 
and larger cyst-like spaces are occasionally found. These have 
smooth inner surfaces and a lining of mucosa often 1 mm. in thick- 
ness. They are in reality miniature uterine cavities. Many of 
these cyst-like spaces contain fresh blood or yellowish blood pigment, 
the remains of old hemorrhages. The small cyst spaces may readily 
be mistaken for blood-vessels, but the larger ones are easily recog- 
nized. Among the most instructive cases reported are those of 
Lockstaedt.^ In his Case 5 there was a diffuse m3^omatous thick- 
ening invading the posterior and part of the anterior wall. At 
several points the myoma had penetrated the outer muscular cover- 
ing and sent prolongations as far as the peritoneum. On section 

^ Lockstaedt, Paul: Ueber Vorkommen und Bedeutung von Driisenschliiuchen 
in den Myomen des Uterus. Monatsschrift f. Geburtshiilfe und Gynaekologie, 
1898, Bd. vii, p. 188. 



4 ADENOMYOMA OF THE UTERUS 

of the tumor numerous round lumina were seen. These had a 
diameter of 2 mm. In the fundus were six roundish depressions 
of the mucosa, into all of which one could easily pass a metallic 
sound, and a bristle could be inserted for a distance of from 1 to 
1.8 cm. into the myomatous tissue. These canals branched with 
one another and also with those in the middle of the tumor. All 
were lined with a clear membrane which was easily loosened from 
the underlying myomatous tissue. In short, the small canals in 
the myomatous tissue were channels from the uterine cavity and 
had a lining of uterine mucosa. 

In his Case 7 Lockstaedt found a diffuse myomatous thickening 
of the posterior wall and of the right side of the uterus. Near the 
fundus he saw five roundish depressions of the mucosa, and from 
these it was possible to pass into the myoma for a distance of 1.5 cm. 
One of the canals was broad enough to be easily opened with the 
scissors, and here one could see that the mucous membrane was 
directly continuous with that of the uterine cavity. Scattered 
throughout the diffuse growth were many cyst spaces, most of them 
filled with reddish-brown or chocolate-colored fluid. In order to 
determine whether these also communicated with the uterine cavity, 
Lockstaedt introduced a solution of Berlin blue into all of them, 
and was thus enabled to show that isolated cyst spaces were indirectly 
connected with the uterine cavity. From such cases we see that 
the uterine mucosa penetrates the diffuse myoma at several points 
and that these down-growths branch in all directions. 

In Fig. 4, p. 26, we see just the earliest stage of such a condition 
as was found by Lockstaedt. Here in the fundus coarse myomatous 
masses are welling into the cavity and a large area of mucosa is 
passing down into the crevice between. With the continued growth 
of the myoma a portion of the uterine cavity would soon be drawn 
into the depth, and in all probability would eventually lose its 
continuity with the parent uterine cavity. 

Rarely, if ever, do we find the slightest trace of glands in the 
outer covering of normal muscle. In the majority of these cases 
besides the diffuse myomatous growth a few circumscribed myomata 



DIFFUSE ADENOMYOMA OF THE UTERUS 5 

are present. These are irregularly scattered, being submucous, 
interstitial, or subperitoneal. They are usually only a few centi- 
metres in diameter, but many attain to 15 cm. or more before the 
uterus is removed. When the uterus is not enlarged, the uterine 
cavity generally presents the usual appearance and is in no way 
altered, as the diffuse myoma does not usually press inward, as a 
submucous myoma invariably does. Case 2754, however, is an 
exception (Fig. 8, p. 42). Here there is a considerable bulging 
into the cavity. 

The uterine mucosa is usually smooth, save for the occasional 
depressions as noted in Lockstaedt's cases; it is of the usual breadth 
or may reach a thickness of from 7 to 8 mm., as is seen in Fig. 1, 
p. 10, and Fig. 23, p. 77. Polypi, so common in cases of discrete 
myomata, are usually absent. 

Histological Appearances . — The surface of the 
mucosa is usually smooth and has an intact surface epithelium 
(Fig. 6, p. 37, Fig. 14, p. 56, and Fig. 24, p. 78). The glands present 
the normal appearance as seen in Fig. 3, p. 19, and Fig. 7, p. 38. 
The stroma of the mucosa just beneath the surface epithelium is 
often slightly edematous or rarefied. The diffuse thickening in 
the uterine walls consists of characteristic myomatous tissue, the 
muscle bundles, however, showing much more interlacing than is found 
in the ordinary discrete myomata. Along the outer or advancing 
margin of the growth the myomatous cells gradually and imper- 
ceptibly merge into the normal muscle cells. The m3^omatous 
tissue, as was noted macroscopically, extends up to but usually 
does not encroach upon the mucosa. In most cases the mucosa 
can be seen dipping down into the diffuse myomatous growth, and 
at such points the muscle bundles run at right angles to the mucosa, 
thus allowing the latter to dip down between them. Sometimes a 
single gland penetrates the myoma. Such a gland presents a 
perfectly normal appearance (Fig. 29, p. 92), and is usually accom- 
panied by the stroma of the mucosa which separates it from the 
muscle. In favorable sections such a gland can be traced far into 
the myomatous tissue. If it meets a barrier in the form of a muscle 



6 ADENOMYOMA OF THE UTERUS 

bundle running parallel with, instead of at right angles to, the uterine 
mucosa, it is deflected along the surface of this until other muscular 
bundles are encountered that are again at right angles to the uterine 
cavity. It then passes still further outward between them. In other 
words, the gland follows the path of least resistance, winding in and 
out in all directions like a rivulet, but always making toward the 
peritoneal surface. While single glands sometimes penetrate, 
larger portions of the mucosa, as a rule, find their way into the muscle ; 
for example, in Fig. 16, p. 58, three glands, accompanied by their 
stroma, can be seen extending into the muscle and spreading out 
in the depth, where more room is met with. In other words, they 
form a funnel with its smaller calibre directed toward the mucosa. 
In Case 3136 the mucosa (Fig. 24, p. 78) invades en masse, while 
in Fig. 6, p. 37, and in Fig. 7, p. 38, the mucosa is seen penetrating 
as the roots of a tree, there being a main trunk with many rootlets 
piercing the myoma in all directions. These glands retain their 
normal appearance and, as can be noted from the drawings, are invari- 
ably surrounded by the normal stroma of the mucosa. These exten- 
sions of the normal mucosa in many cases can be traced by direct con- 
tinuity for at least 1 cm. In Fig. 6, p. 37, they can be followed for 
over 1.5 cm. Of course, with the windings in and out of the down- 
growths of the mucosa the continuity will be lost in the depth. 
Nevertheless, serial sections and injection in favorable cases, as 
carried out by Lockstaedt, show that the bunches of glands found 
in the depth are direct extensions from the mucosa. In the out- 
lying portions of the diffuse myoma round, oval, triangular, or 
irregular islands of glandular tissue are encountered. These consist, 
as a rule, of essentially normal uterine glands (Fig. 14, p. 56), lined 
with one layer of cylindrical ciliated epithelium and surrounded by 
the normal stroma of the mucosa. 

Not infrequently these glands become cystic, the dilatation 
varjdng from 1 to 9 or more millimetres in diameter. Such dilata- 
tions are easily explained by the kinking and bending to which the 
glands are subjected by the surrounding and ever-growing myoma- 
tous tissue. The epithelium of the dilated glands is usually pale- 



DIFFUSE ADENOMYOMA OF THE UTERUS 7 

staining and somewhat flattened. The cyst spaces frequently 
contain desquamated epithehum, sometimes are partially filled 
with blood pigment and also contain a varying quantity of blood. 
In several instances we have noted round giant cells containing 
from four to eight nuclei in their centres and probably originating 
from the coalescence of degenerated epithelial cells. Some of the 
large spaces are not dilated glands, but represent cross-sections of 
the deep depressions from the mucosa, as noted in Lockstaedt's 
cases. Here the entire mucosa is carried into the myoma, and on 
cross-section we have a space lined with one layer of surface epithelium 
and surrounded by typical uterine mucosa. Of course, the mucosa 
on one side may be thinned out on account of the irregular stretching 
of the myomatous tissue, and then we have a picture corresponding 
to the chief canal — the Hauptkanal of von Recklinghausen. The 
miniature uterine cavity seen in Fig. 21, p. 72, although situated near 
the peritoneal surface, is probably similar in origin. From the 
pathological description it is seen that the uterine glands were 
found extending into the diffuse myoma; and again, a reference to 
Fig. 22, p. 74, which is an enlargement of a portion of Fig. 21, shows 
a mucous membrane indistinguishable from that lining the uterine 
cavity — a mucosa that is peculiar to the uterus and never found 
elsewhere. The glands in the diffuse myoma occasionally show 
some branching, as noted in Fig. 16, p. 58, Fig. 22, p. 74, Fig. 26, 
p. 81. This finding is sometimes noted in a normal uterus, and here, 
where the mucosa has such free play and where the glands are so 
long, we would naturally expect some branching. On the whole, 
however, they are remarkable for their regular shape. 

The glands are naturally most abundant in the vicinity of the 
mucosa ; they gradually diminish in number in the outer myomatous 
zone and are completely wanting in the normal outer muscular 
capsule. In short, where the myoma ends they cease. This is 
well shown in Fig 3, p. 19, Fig. 6, p. 37, Fig. 9, p. 43, and Fig. 24, 
p. 78. In some cases, although the glands in the diffuse myoma are 
identical with uterine glands, their origin from the mucosa cannot 
be clearly proved. In the majority of these cases, however, careful 



8 ADENOMYOMA OF THE UTERUS 

examination of serial sections will show that at several points at least 
the glands of the mucosa are continuous with those in the depth. 

CASES OF DIFFUSE ADENOMYOMA IN "WHICH THE UTERUS RETAINS A 
RELATIVELY NORMAL CONTOUR 

Had we been told several years ago that in an examination of 
1283 myomatous uteri diffuse adenomyomata were found 73 times, 
that is, in about 5.7 per cent., we should certainly have been tempted 
to doubt the veracity of the author. Nor can such a statement 
even now be accepted without ample proof. Accordingly it has 
been deemed advisable to give the essential features of each of the 
cases. In the brief description which we have just given of this 
disease only the sahent points were discussed. Many other inter- 
esting data may be gleaned from a careful perusal of the individual 
records. 

Gyn. No. 3418. Path. No. 661. 

Diffuse adenomyoma of the posterior 
uterine wall (Figs. 1 and 2). 

K. B. N., married, aged forty, white. Admitted April 3, 
1895. Complaint on admission: Painful and profuse menstruation. 
The patient began to menstruate when fourteen years of age. The 
periods occurred at intervals of from three to four weeks, were 
profuse, but not accompanied by much pain. She has been 
married seventeen years; had one difficult, but non-instrumental, 
labor sixteen years ago, after which she was confined to bed for six 
weeks on account of chills and fever, which were followed by ab- 
dominal pains. Eleven years ago she had a miscarriage. Immedi- 
ately after the birth of the child the menses became profuse and there 
was a discharge of dark, clotted blood. Pain was felt in the lower 
abdomen, also in the back. It commenced a few hours before the 
flow and lasted until the menses were over. The patient has never 
been strong; when twelve years of age she had malaria, and when 
fifteen, pneumonia. Her family historj'^ on both sides is decidedly 
tuberculous, both grandfathers, her mother, one aunt, and two 
cousins having died of phthisis. 



DIFFUSE ADENOMYOMA OF THE UTERUS 9 

Present Condition . — The patient is a well-nourished 
but rather anaemic woman, w^eighing 140 pounds. Her tongue 
is coated; appetite good. She has an occasional headache; ex- 
periences no difficulty in locomotion ; her feet and ankles occasionally 
swell; urine normal; the last menses ceased two weeks ago after a 
duration of ten days. On vaginal examination myoma uteri was 
diagnosed. 

April 6, 1895. Operation . — An incision 15 cm. long 
was made in the median line, and the tumor lifted out of the pelvis. 
The ovarian vessels, round ligaments, and uterine vessels were 
tied and the uterus was amputated low down. The cervical lips 
were then brought together, and the peritoneum from the posterior 
pelvic wall was united with that from the anterior. The patient 
was discharged May 3d feeling perfectly well. 

Gyn.-Path. No. 661 .—The specimen consists of the 
enlarged uterus with its appendages intact. The uterus is pear- 
shaped and measures 12 cm. in length, 10 cm. in breadth, and 8 cm. 
in thickness. It is pinkish in color, smooth and glistening. A 
portion of the cervical canal measuring 2 cm. in length is present; 
its mucosa is pearly white in color, smooth and glistening, and has 
almost entirely lost its rugous appearance. The uterine cavity 
measures 4.5 cm. in length and is 5.5 cm. in breadth in its upper 
portion. The posterior wall bulges slightly into the cavity. The 
mucous membrane is smooth, but presents a mottled appearance, 
being the seat of extensive hemorrhage. It is 8 mm. in thickness. 
The anterior uterine wall averages 2.5 mm. in thickness. The 
posterior wall is 5 cm. thick and maybe di- 
vided intotwo portions: an inner and thick- 
ened, which is coarsely striated and which 
looks very much like myomatous tissue, and 
an outer, resembling normal uterine muscle 
(Fig. 1). The contrast is much sharper after the specimen has been 
hardened in Miiller's fluid, the coarsely striated portion staining 
lightly, the normal muscle deeply. 

On careful examination of the hardened specimen, grayish- 



10 



ADENOMYOMA OF THE UTERUS 



brown granular areas are seen scattered throuohout the thickened 



portion of the wall. 




Fig. 1. — Diffuse adenomyoma of the posterior wall 
OF THE UTERUS. (Natural size.) 
Gyn.-Path. No. 661. The uterus has been 
amputated through the cervix. The anterior uterine 
wall is unaltered. The posterior wall from cervix to 
fundus is greatly thickened, owing to the presence of a 
diiTuse myomatous growth lying between the mucosa and 
the outer covering of normal muscle. This diffuse growth 
consists of fibres forming whorls but also passing in all 
conceivable directions. It encroaches to a slight extent 
on the uterine cavity. At a is seen the junction between 
the diffuse myoma and the normal muscle. The fibres 
of the one, however, blend imperceptibly with the other, 
and it would be impossible to shell this growth out, as 
can be done with discrete myomata. Near the internal 
OS is a small polyp. The uterine cavity is somewhat 
lengthened. The mucosa lining the anterior wall is of 
the normal depth, but that covering the posterior wall 
is considerably thickened, and at two points indicated by 
b it can be traced for a considerable distance into the 
myoma. At c, just along the lower margin of the growth, 
the mucosa can be seen penetrating into the uterine wall 
for fully 1.5 cm. (For the. histological appearance of the 
posterior wall see Fig. 2.) 



These are round or irregular in contour, 
and as one approaches 
the uterine cavity are 
seen to merge directly 
into the mucosa. Even 
on macroscopic examina- 
tion it is evident that 
at least in the superficial 
areas are portions of the 
mucosa that dip down 
into the tumor. 

Scattered here and 
there throughout the 
tumor are cavities, the 
largest of which is about 
5 mm. in diameter. They 
have a smooth, glisten- 
ing inner surface. Some 
of them are filled with 
blood. Along one mar- 
gin of the tumor is a 
myomatous nodule 1 cm. 
in diameter. The outer 
portion of the uterine 
wall, which corresponds 
to the uterine muscle, 
averages 1 cm. in thick- 
ness. 

Right side : The tube 
is 9 cm. long, 6 mm. in 
diameter. It is free 
from adhesions and has 
a patent fimbriated ex- 
tremity. The parovarium 



DIFFUSE ADENOMYOMA OF THE UTERUS 11 

is intact. The ovary is 3.5 by 2.5 by 1.8 cm. It is free from adhe- 
sions, and on its under surface contains two shghtly dilated Graafian 
folUcles. 

Left side: The tube is 7 cm. long and .8 cm. in diameter. 
It is free from adhesions and has a patent fimbriated extremity. 
The parovarium is intact. 

The ovary is 3.5 by 2.5 by .5 cm. and is slightly cirrhotic. On 
its under surface is a corpus luteum, 2.5 by 1 cm. 

Histological Examination . — The cervical glands 
are in most places normal, but here and there have proliferated. 
The epithelium covering the surface of the cervical mucosa is of the 
high cylindrical variety; near the junction of the internal os, how- 
ever, it suddenly changes and the mucosa is covered with several 
layers of squamous epithelium. Above this point the typical 
cervical epithelium is again found. The mucosa covering the pos- 
terior wall of the uterus has an intact surface epithelium. Here 
and there little knob-like masses of the mucosa project into the 
uterine cavity. The uterine glands in the superficial portion are 
moderate in number and are small and round on cross-section. In 
the deeper portions they show considerable branching, and in some 
places it looks as if one gland gave off three or four branches; this 
appearance is probably due to a marked convolution of the glands. 
In several places the glands are seen extend- 
ing down into the underlying tumor. This 
is most noticeable near the upper part of the 
uterine cavity, where longitudinal sections 
of two or three glands can be seen passing 
between muscle bundles into the depth of the 
tumor. This is clearly demonstrable to the naked eye. The 
stroma is rarefied (Fig. 2). 

The individual stroma cells have oval vesicular nuclei and are 
slightly swollen. Scattered here and there throughout the stroma 
are small round cells occurring either singly or in clumps. The 
superficial portions of the mucosa show considerable hemorrhage. 
The coarsely striated thickening in the posterior wall is composed 



12 



ADENOMYOMA OF THE UTERUS 







Fig. 2. — Diffuse adexomyoma of the posterior uterine wall. (3 diameters.) 

Gyn.-Path. No. 661. The section represents the upper half of the posterior wall of 
the uterus seen in Fig. 1. The wall is divided into three distinct zones, an inner, a, consisting of 
the uterine mucosa; a middle zone, b, thick and coarse, made up of diffuse myomatous tissue; and 
an outer zone, c, composed of normal muscle. The mucosa, although increased in thickness, is 
normal. The surface epithelium is intact and the glands present the usual appearance. The 
diffuse myomatous growth has many islands of glands scattered throughout it. These consist 
of practically normal uterine glands and are surrounded by the characteristic stroma of the mucosa. 
Some of the glands are much dilated. Occasionally a gland occurs singly and lies in direct contact 
with muscle. At e the gland has retracted from the surrounding stroma. The origin of the gland 
elements in this diffuse myoma is clear, as at d we see the uterine mucosa extending directly into 
the myoma. 



DIFFUSE ADENOMYOMA OF THE UTERUS 13 

of non-striped muscle fibres, which are cut longitudinally and trans- 
versely. This tissue is denser than normal uterine muscle, but 
otherwise closely resembles it. Between the bundles of muscle 
fibres, and also between the individual fibres, there is considerable 
infiltration with small round cells. Scattered freely throughout 
the tumor are glands. The majority of these are found in groups; 
some, however, occur singly. In many places they are seen on 
cross-section, where they appear as rows of oval or round glands. 
Some have been cut longitudinally and are cylindrical; others are 
curved. A few appear to have secondary glands opening into them. 
The glands as a whole are lined with one layer of cylindrical epithe- 
lium, on which it is possible in many places to make out cilia. A 
few of them are dilated. The epithelium of some is intact; in others 
it has become flattened or has disappeared. Some of the dilated 
glands are empty, others contain desquamated epithelium and 
granular material. Some of the desquamated cells are swollen and 
their protoplasm contains yellowish-brown, granular pigment. 

The largest gland is filled with blood. In many of the glands 
the epithelium has become desquamated, and the gland is only 
recognized as a space partially or completely filled with desquamated 
cells. The groups of glands, and also most of those occurring singly, 
are surrounded by stroma which separates them from the muscle. 
This stroma is similar to that of the normal uterine mucosa. Here 
and there cross-sections of three or four glands are seen where the 
epithelial cells lie directly in contact with the muscle. In a good 
many places stroma cells contain brown, granular pigment. At 
one or two points a very curious picture is noted. At one end of a 
space between muscle bundles it is possible to make out a gland 
undergoing degeneration; on tracing this a little further, we see 
three oval spaces forming a chain; these are almost completely 
filled with small, round cells and cells having oval vesicular nuclei, 
which look a little like those of epithelioid cells. Each of these 
masses of cells contains one or more giant cells, which are round, 
oval, or elongated-oval; their nuclei are vesicular and situated 
in the centre of the cell or around the periphery. They remind one 



14 ADENOMYOMA OF THE UTERUS 

somewhat of tubercles, but we believe them to be degenerated 
glands. No tubercle bacilli could be detected in these areas; nor 
was there any caseation. 

There is no definite arrangement of the muscle around the 
bunches of glands. It looks as if the glands just filled in the spaces 
between muscle bundles. At one side of this new growth is a typical 
myomatous nodule, 1 cm. in diameter; this is entirely devoid of 
gland elements. The outer zone of the posterior wall, consisting 
of uterine muscle, is normal. The mucosa covering the anterior 
uterine wall is normal. Both tubes and ovaries are normal. 

Gyn. No. 12,681. Path. No. 9517. 

Diffuse myomatous thickening of both 
anterior and posterior uterine walls; large 
polyp in the body of the uterus; diffuse adeno- 
myoma of the posterior wall; slight adeno- 
myomatous tendenc}^ in the anterior wall. 

F. Y., married, aged fifty-nine, white. Admitted Feb. 7, 1906; 
discharged March 12, 1906. The menses commenced at fourteen 
and were regular until ten years ago. At this time the periods 
became irregular and were from three to seven weeks apart. The 
flow is now more profuse and there is flooding. The patient has 
had pain in the region of the uterus for some time. The last period 
came on three weeks ago. The patient has been married thirty- 
nine years, has had eight children and two miscarriages. The 
oldest child is thirty-eight, the youngest twenty. Two years ago 
she consulted a physician, who removed several small polypi from 
the cervical canal. The bleeding diminished somewhat after this, 
but has been increasing again of late, and is now as abundant as 
before the operation. The patient has had no pain except a feeling 
of dull aching about the bladder. She is constipated. There is 
shortness of breath and a slight increase in frequency of micturition. 

Protruding from the os is a polyp 5 mm. in diameter. The 
fundus is not definitely outlined. 

Operation . — Removal of small cyst from the left labium 



DIFFUSE ADENOMYOMA OF THE UTERUS 15 

majus; hysterectomy; double salpingo-oophorectomy. The pa- 
tient's highest temperature was 100.8^ F. She made an uneventful 
recovery except for a superficial breaking down of the incision. 

Path. No. 951 7. — The specimen consists of a myomatous 
uterus 10 cm. in length, 9 cm. in breadth, and 8 cm. in its antero- 
posterior diameter. It is smooth and glistening. The anterior 
wall varies from 3.5 to 4 cm. in thickness and presents a coarse 
striated appearance. In the fundus is a discrete myoma 3 mm. in 
diameter. The posterior wall varies from 2.3 to 3 cm. in thickness. 
It also presents a rather coarse striation. Just to the left of the 
cervix is a myoma 2.5 cm. in diameter, and below the cervix is a 
myoma approximately 6 cm. in diameter. The right tube ofTers 
nothing of interest. The ovary is covered with a few adhesions. 
It is very small. The left tube is normal. The ovary is somewhat 
mutilated. The mucosa varies from 2 to 4 mm. in thickness, and 
projecting from the left side is a polyp 2 cm. in length, 1 cm. in 
thickness. 

Sections taken from the posterior wall show an intact surface 
epithelium. The glands are normal. The stroma presents the 
usual appearance. The most striking point ob- 
served with the dissecting microscope is that 
at many points the glands can be traced 
into the depth. At one point they can be 
followed by continuity for 3 mm. In other 
places several glands run down in the form of a funnel. Scattered 
throughout the thickened diffuse myomatous wall are glands and 
islands of uterine mucosa. Some of them contain only a single 
gland, others cross-sections of eight or more. Very few of these 
glands show dilatation. 

Sections from the anterior wall also show a great deal of diffuse 
thickening. We have an intact surface epithelium, normal glands, 
and a stroma which in its superficial portion shows considerable 
hemorrhage. At several points far down in the depth we have 
a few isolated glands. There is here an adenomyomatous ten- 
dency, which is not, however, very marked. In the anterior wall 



16 ADENOMYOMA OF THE UTERUS 

we have several discrete myomata, the largest being 1.5 cm. in 
diameter. 

Diagnosis . — Diffuse myomatous thickening of both anterior 
and posterior uterine walls with marked extension of the mucosa 
into the posterior wall and slight penetration of the uterine mucosa 
into the anterior wall; discrete myomata chiefly in the cervical 
tissue; normal appendages. 

Gyn. No. 11,850. Path. No. 8197. 

Diagnosis: Interstitial and subperitoneal 
uterine myomata. Diffuse adenomyoma in 
the uterine walls, the glands originating 
in the mucosa. 

C. B., aged thirtj^-nine, white, married. Admitted January 30, 
1905. 

Complaint: abdominal tumor. The patient had one child, 
eight years ago; no miscarriages. Menses at sixteen. Were 
regular ever\^ four weeks. Flow lasted four days, but lately has 
been of only one day's duration. Flow very scant, with clots. 
The pain was formerly cramp-like, but lately only slight. There 
has been no bleeding since the last period. After the birth of the 
child, eight years ago, she had what was supposed to be an abscess 
of the uterus. This opened spontaneously. She made a satis- 
factory recovery, and in 1900 she had a second abscess, which 
opened spontaneously. 

Operation . — Hystero-myomectomy. 

The uterus was small. On its anterior surface was an irregular 
myomatous tumor about 18 by 5 cm. The tubes and ovaries on 
each side were ver}^ much adherent from a chronic inflammatory 
process. The myoma was first bisected and loosened from the 
bladder. The uterus was removed and later the appendages. The 
left ovar}^ was firmly adherent to the rectum. In cutting it away 
a small piece of ovarian tissue was left behind. Convalescence was 
not complicated. The highest temperature was 100.4° F., twenty- 
four hours after operation. 



DIFFUSE ADENOMYOMA OF THE UTERUS 17 

Path. No. 819 7. — The specimen consists of the uterus 
amputated above the cervix. It has been bisected. Attached to 
the anterior wall is a large interstitial mj^oma. Both tubes and a 
part of the left and of the right ovary are present. The uterus 
is normal in size. Its cavity measures 4 cm. in length. Springing 
from the anterior wall of the uterus is a myomatous growth, 18 by 
5 cm. The tumor does not encroach at all upon the uterine cavity. 
There are several small myomatous nodules scattered throughout 
the uterine wall. These are interstitial. There are dense adhesions 
over the surface of the tumor. The right tube and ovary are ad- 
herent. The fimbriated end is lost in the tubo-ovarian mass. The 
left ovary is cystic. The left tube is normal. Only a portion of 
the left ovary has been removed. 

Sections from the endometrium show that the glands are perfectly 
normal except that here and there there is a dilatation. At some 
points there is a distinct tendency for the 
glands to extend into the depth, and at one 
point we have definite islands of mucosa at 
least 4 mm. from the surface. A direct connection 
between these and the surface mucosa can be traced. Around these 
islands the muscle shows a definite myomatous tendency. Sections 
from one of the myomata yield the usual appearance. There is 
some hyaline transformation. 

Diagnosis . — Interstitial and subperitoneal uterine myomata ; 
definite adenomyoma with the glands originating from the mucosa. 

Gyn. No. 2573. Path. No. 163. 

Diffuse adenomyoma occupying both the 
anterior and posterior uterine walls (Fig. 3) ; 
discrete subperitoneal, interstitial and sub- 
mucous myomata. Hysterectomy. Recovery. 

M. B., married, aged fifty, white. Admitted Feb. 7, discharged 
March 10, 1894. 

The patient has been married twenty-eight years and has had 

five children, the youngest of whom is now sixteen. Flow usually 
2 



18 ADENOMYOMA OF THE UTERUS 

returned in ten months. One miscarriage, thirteen years ago, 
at six weeks. 

Menses irregular until marriage, with profuse flow and some 
pain; periods regular after marriage. Last spring the menses 
began to decrease gradually, the pain also became less. The last 
period occurred in June, 1893 (menopause?). After the cessation 
of the flow in June, 1893, the patient felt very well. In August, 
1893, she had a slight flow at about the menstrual period, and at 
this time commenced to feel weak and to have a profuse yellowish 
leucorrhoeal discharge. Since November, 1893, she has had constant 
hemorrhages. 

Examination . — Douglas' cul-de-sac is filled with a hard, 
immovable mass, from which the uterus cannot be differen- 
tiated. 

Operation . Feb. 10, 1894. Dilatation and curettage. 
Double salpingo-oophorectomy. Hystero-myomectomy. Uterus 
dilated and curetted with removal of a large quantity of mushy 
endometrial tissue. Retroflexed adherent myomatous uterus re- 
moved. 

Maximum temperature 100.8° F. on eleventh day. Varied 
between 98.6° and 100.5° F. for over three weeks. Recovery. 

Gyn.-Path. No. 163 . — The specimen consists of the 
uterus, tubes, and ovaries. The uterus is uniformly enlarged, being 
8 cm. in length, 7 in breadth, and about 7.5 in its antero-posterior 
diameter. It is smooth and glistening, but situated on the posterior 
surface are two small, hard nodules about 5 mm. in diameter. These 
are myomata. The anterior uterine wall varies from 2 to 3 cm. in 
thickness. Its muscular tissue is rather coarse, especially in its 
inner half, and scattered throughout it are numerous myomata, 
some reaching 1.5 cm. in diameter. The posterior uterine wall 
varies from 2 to 3.5 cm. in thickness. Its muscular tissue near the 
uterine cavity is coarse in texture. Scattered throughout it are 
several small myomata. Some of these encroach to a slight extent 
on the uterine cavity. The uterine cavity is 7 cm. in length and 
7.5 cm. in breadth at the fundus. A description of the mucosa can 



DIFFUSE ADENOMYOMA OF THE UTERUS 



19 



^-r 




-— (1 



-4 



{^.iBe'cke^. 



Fig. 3. — Diffuse adenomyoma of the posterior uterine wall. (3J diameters.) 

Gyn.-Path. No. 163. The section is taken from the upper part of the uterine 
cavity, as shown by the position of a, which denotes the fundus. Tlie uterine walls with the 
higher power show a slight myomatous transformation. There is considerable encroachment 
of the growth on the uterine cavity. At h the mucosa is of the usual thickness and is normal in 
appearance. At the fundus as seen at c it is thickened, but mechanically injured. At d the 
mucosa penetrates the diffuse growth for a short distance and at (/' can be traced far into the 
muscle. At the latter point there is also a direct communication between the two down-growths, 
e is a cystic uterine gland. Scattered throughout the inner half of the uterine wall are numerous 
islands of uterine glands surrounded by deeply stained areas — the normal stroma of the mucosa. 
Here and there is a small gland lying in direct contact with the muscle. There are also numerous 
deeply stained areas, as represented by /. These consist of stroma of the mucosa devoid of gland 
elements. That the glands of this growth are derivatives of the uterine glands is evident. 



20 ADENOMYOMA OF THE UTERUS 

be of little value, as the greater portion of it had been removed 
with the curette prior to operation. 

Histological Examination . — Sections from pro- 
tected portions show that the surface epithelium is intact. The 
uterine glands present the usual appearance; some of them, however, 
are considerably dilated. The stroma of the mucosa presents the 
usual appearance. On the whole, we should consider the mucosa 
normal. At one point, however, near the fundus the glands show 
a peculiar branching and the epithelium is somewhat flattened, 
but the individual cells show no suspicious changes. The diffuse 
thickening in both the anterior and posterior walls is due to a myo- 
matous transformation of the muscle. In some places this is very 
pronounced, but it is to a great extent limited to the inner half of 
the uterine walls. In many places the mucosa has 
penetrated the diffuse myoma for a distance 
of 1.5 cm. and in several places the direct 
extension into the depth can be traced for 
a distance of 6 mm. (Fig. 3). In the depth these down- 
growths of the mucosa are recognized as islands of mucous membrane 
surrounded by myomatous tissue. These islands sometimes contain 
a dozen or more glands, normal in appearance and surrounded by the 
characteristic stroma. Some of the glands are much dilated, and 
occasionally an isolated gland is found lying between muscle bundles, 
but even then it is usually separated from the muscle by the stroma 
of the mucosa. The diffuse adenomyomatous condition, although 
present in both the anterior and posterior walls, is more pronounced 
in the posterior. Both tubes and ovaries are normal. 

Diagnosis . — Diffuse adenomyoma occupying both the 
anterior and posterior uterine walls; discrete subperitoneal, in- 
terstitial, and submucous myomata; normal appendages. 

H, A, K. Sanitarium No. 193 1. Path. No. 9367. 
Subperitoneal, interstitial, and submu- 
cous uterine myomata; commencing adeno- 
m. y o m. SL . 



DIFFUSE ADENOMYOMA OF THE UTERUS 21 

J. H., aged forty-nine, white. Admitted May 11, 1905. The 
patient complains of an excessive flow. In 1893 a myoma was 
diagnosed. This has apparently not increased in size. The patient 
now suffers chiefly from pressure on the bladder. There is a great 
deal of pain in the region of the left ovary and in the lower part of 
the abdomen. On May 12, 1905, with a pair of forceps, a myoma 
was drawn down out of the body of the uterus. Examination per 
rectum showed that the tumor was the size of a cocoanut and that 
there were several others. She soon left the hospital, but returned 
on October 6th. The last menstrual flow had been very severe. 

Operation Nov. 18, 1905 . — Hystero-myomectomy, 
right salpingo-oophorectomy. The patient made a very satisfactory 
recovery. 

Path. No. 936 7. — The specimen consists of the uterus, 
which is rather uniformly enlarged, and which has been amputated 
through the cervix. It is 11 cm. in length, 12 cm. in breadth, and 
12 cm. in its antero-posterior diameter. Occupying the anterior 
wall is an oval mass, 8 by 6 cm., presenting a typical myomatous 
appearance. Scattered throughout the uterine walls are numerous 
interstitial myomata, and there are also two submucous nodules, 
the larger 2.5 cm. in diameter. The uterine mucosa is apparently 
very thin. The right tube and ovary look normal. 

Histological examination shows the endometrium 
to be perfectly normal. Over the surface of a submucous myoma 
from the fundus, there is a distinct mj^omatous thickening, and 
covering its surface is an intact surface epithelium. Riddling 
the myoma for a short distance are normal 
uterine glands, some of which show a direct 
connection with the uterine mucosa. A little 
further on are two small myomata projecting into the cavity, and 
on either side of them is normal mucosa. This is rather remarkable, 
as there is really no encroachment upon the uterine cavity, the 
myomata just taking the place of the normal uterine mucosa. 

Diagnosis . — Subperitoneal, interstitial, and submucous 
uterine myomata; commencing adenomyoma. 



22 ADENOMYOMA OF THE UTERUS 

Gyn. No. 12,599. Path. No. 9366. 

Slight grade of endometritis, diffuse thick- 
ening of both the anterior and posterior uterine 
w a 1 1 s ; d i f f use a d e n o my o m a of the anteriorwall 
with the glands originating in the mucosa. 

S. A. B., married, aged forty-three, white. Admitted January 
10, 1906; discharged January 31, 1906. Complaint: uterine 
hemorrhages. The menses commenced at eleven and occurred 
every three or four weeks until a year ago. Since then the periods 
have been irregular and prolonged, with flooding, at times accom- 
panied by cramps, which, however, have not been severe. Flow 
normal, lasting from six to eight days. The last period began one 
month ago and has persisted up to the present time. The patient has 
been married twenty-one years, has had three children and two 
miscarriages. The oldest child is twenty, the youngest fourteen. 

For fourteen years the patient has noticed that ten days after 
the menses the abdomen would swell markedly and she would have 
the sensation as if everything were falling out of the abdomen. 
Six months ago she had her menstrual period and the bleeding per- 
sisted for one month; it could not be controlled with medicine. 
Three days before admission the bleeding became so marked that 
the uterus was packed. 

Operation . — Hysterectomy, amputation through the cer- 
vix. The history was somewhat suggestive of carcinoma, and 
as the uterus had been recently curetted we prepared to do an 
abdominal hysterectomy, if necessary, but on opening the abdomen 
noted the coarse striated appearance of the uterus and consequently 
amputated through the cervix. The patient made a satisfactory 
recovery. The highest post-operative temperature was 100° F. 

Path. No. 9366 . — The specimen consists of the uterus 
amputated through the cervix and of the appendages on both sides. 
The portion of the uterus present is 7 cm. in length, 8 cm. in breadth, 
and 6.5 cm. in its antero-posterior diameter. Anteriorly it is 
smooth and glistening. Posteriorly it is covered with a few adhe- 
sions. The uterine walls are firm. The posterior wall varies from 2.5 



DIFFUSE ADENOMYOMA OF THE UTERUS 23 

to 3 cm. in thickness. The anterior also reaches 3 cm. in diameter. 
The mucosa is apparently thin on the posterior wall and on the 
anterior reaches 2.5 mm. in thickness. The right tube is covered with 
a few adhesions. Its fimbriated end is patent. The right ovary, 
apart from a few adhesions, is normal. The left tube is normal. 
The left ovary is slightly adherent. 

Sections from the anterior uterine wall 
show that it is riddled with islands of uterine 
mucosa. In a good many places these islands are irregular 
and are surrounded by a zone of muscle fibres lying parallel with 
the islands. External to this parallel zone is a circular zone. In 
a good many places the glands occurring in the muscle are dilated 
and at numerous points are seen miniature cavities. These are 
lined with one layer of epithelium resting on the underlying stroma, 
in which typical uterine glands are situated. The myomatous 
tissue forming this diffuse growth is not very sharply differentiated 
from normal uterine muscle. Some of the glands have two layers 
of cells which stain palely, and the appearances are rather suggestive 
of pathological changes. It will be noted that the glands in such 
an adenomyoma might very readily have undergone carcinomatous 
changes. 

On examining further sections it is found 
that the mucosa of the anterior wall can be 
traced into the depth for 1.5 cm. Here it ends 
abruptly. The endometrium shows numerous polymorphonuclear 
leucocytes. The posterior wall shows diffuse myomatous thickening 
but contains no glands. 

Diagnosis . — A mild grade of endometritis; diffuse myoma- 
tous thickening of the anterior and posterior uterine walls; definite 
adenomyoma of the anterior wall with the glands originating from 
the mucosa. 

Gyn. No. 3614. Path. No. 788. 
Diffuse myomatous thickening of the 
uterine walls with extension of a large area 



24 ADENOMYOMA OF THE UTERUS 

of mucosa into the depth between the myo- 
ma t a (Fig. 4). Interstitial uterine myomata; 
hemorrhage into and thickening of the mucosa; 
general pelvic peritonitis. 

Mrs. D. G., aged forty-three. Admitted June 29, 1895. Com- 
plaint : pain in the lower part of the abdomen and profuse, painful 
menstruation. She has been married twenty-five years, but has 
never been pregnant. Menstruation began during the sixteenth 
year and continued to be regular until five j^ears ago. It has 
always been free and at times painful. Her family history is nega- 
tive. At seventeen she had typhoid fever with meningeal symptoms, 
and since then her health has been poor. The present illness dates 
back five years. At this time she passed several dark, tarry and 
red masses from the vagina. These appeared to be covered with a 
thin membrane and their passage was accompanied by paroxysms 
of pain. After this, menstruation became irregular and very profuse, 
sometimes lasting two weeks. The discharge was very dark in 
color and frequently clotted. About the second day of menstrua- 
tion severe pain would commence. This would last throughout 
the period, and has at times been so severe that it was necessary 
to keep her under the influence of chloroform. The last period 
came on four weeks ago, the one before that six months previously. 
Four weeks ago she noticed a tumor in the lower part of the abdomen. 
This was freely movable. 

In Januar}^ 1894, an exploratorv'^ section was made. Nothing 
was done, as the tumor was supposed to be malignant. After the 
operation the pain diminished and the patient left improved. 

Present Condition . — The patient is emaciated and 
anaemic, the tongue is clean, the bowels are constipated. She has had 
a water}'- discharge which has persisted for the last four years. This 
is slightly offensive and varies considerably in color; at times it is 
yellow; at other times it has a greenish tinge. It is often tinged 
with blood, and is profuse. Menstruation is frequent and at times 
painful, and during recent years there have bieen sensations of weight 
and pain in the region of the rectum. Locomotion and exercise 



DIFFUSE ADENOMYOMA OF THE UTERUS 25 

occasion a great deal of pain in the lower abdomen. Abdominal 
pressure, however, does not cause any discomfort. 

Operation July 1, 1895 . — After breaking up numerous 
adhesions to the anterior abdominal wall the uterus could be lifted 
up. It was amputated from left to right in the usual manner and a 
drain was brought out through the vagina. On the second daj^ 
the temperature rose to 100.6° F. For several days it ranged be- 
tween 100° and 101° F. On July 15th the cervix was dilated, and 
about 70 c.c. of pus escaped. On the twenty-fifth day the tempera- 
ture reached normal, and on August 12th the patient was discharged 
feeling perfectly well. The abdominal wound in this case broke 
down and discharged for a few days, but on July 20th had healed 
completely. 

Path. No. 788 . — The specimen consists of the uterus with 
intact appendages. The uterus is 11 by 9 by 9 cm. Anteriorly 
and posteriorly it is covered with dense adhesions. It is soft and 
yielding on pressure. The uterine cavity measures 6 cm. in length 
and 6 cm. in breadth. At the fundus the mucosa is bluish-red in 
color, very irregular, and presents numerous nodules which ysltv 
from 1 to 3.8 cm. in diameter. The surface of the mucosa over 
some of these nodules is smooth and glistening, but for the most 
part it presents a rough appearance. Over the fundus are numer- 
ous adhesions passing from the anterior to the posterior surface. 
The mucosa varies from 1 to 7 mm. in thickness. The uterine 
muscle averages 3 cm. in thickness. Situated in the anterior wall 
is a firm nodule, 1.5 cm. in diameter, presenting the typical myoma- 
tous appearance (Fig. 4). The fundus is occupied by a tumor 
approximately 9 cm. in diameter. On section the central portion 
of this tumor over an area 6.5 cm. in diameter has undergone degen- 
eration. It consists of a soft, yielding, whitish tissue held in posi- 
tion by delicate bands. 

Right side: The tube is 8 cm. in length. It is covered with 
dense adhesions. Its fimbriated end is patent. The ovary is 
2.5 by 2.5 by 1 cm. and shows a dilated follicle. 

Left side: The tube is 7 cm. in length and averages 5 mm. in 



26 



ADENOMYOMA OF THE UTERUS 



diameter. It is free from adhesions. The ovary is small and 
covered with dehcate vascular adhesions. 




Fig. 4. — Diffuse adenomyomatous thickenixg in the fundus and posterior uterine wall 
with extension en masse of the mucosa into a large crevice between myomatous 
MASSES. (Natural .size.) 

Gyn.-Path. No. 788. The myoma is welling into the uterine cavity, and into 
the space between myomatous masses a large area of mucosa is flowing. With the continued 
growth of the myomatous tissue this mucosa would in all probability be nipped off and carried 
outward, thus forming a large i.sland of mucosa surrounded by myomatous tissue. 



On section of the specimen after hardening in Miiller's fluid, 
the uterine walls are found to be divided into two distinct layers. 



DIFFUSE ADENOMYOMA OF THE UTERUS 27 

In the anterior wall the inner layer is 2 cm. in breadth. This differs 
from the outer layers and does not stain as deeply. In a few places 
small myomata are seen scattered throughout the thickened part 
of the wall. Eight mm. beneath the mucosa is an area of mucous 
membrane 8 mm. in diameter. In some places the 
uterine mucosa can be* seen flowing into the 
myomatous growth. The outer muscular covering looks 
like normal muscle. The posterior wall varies from 4 to 5 cm. in 
thickness. It is also divisible into two layers, but the coarse myo- 
matous arrangement occupies nearly the entire wall. The uterine 
mucosa extends out for a distance of fully 2 cm. and is invading 
the myoma. 

Histological Examination . — The epithelium cov- 
ering the cervical mucosa is intact and the cervical glands are normal. 
In the vicinity of the broad ligament are a couple of glands lined 
with cylindrical epithelium. They resemble uterine glands and are 
surrounded by a small amount of stroma similar to that of the 
uterine mucosa. The uterine mucosa has an intact surface epithe- 
lium. Its glands are very abundant. In its superficial portions 
they are for the most part small and round; and on cross-section, 
in the vicinity of the muscle considerably dilated. In favorable 
sections one can trace the gland, which is narrowed in its upper 
portion, downward until it becomes dilated. The gland cavities 
are either empty or contain swollen desquamated cells or blood ; in a 
few are polymorphonuclear leucocytes. The stroma of the mucosa 
is, on the whole, denser than usual. Scattered throughout the 
superficial portion of the stroma are a few small round cells and a 
few polymorphonuclear leucocytes. Here and there the glands are 
seen to extend a short distance into the muscle. Where the muscle 
is gathered up into folds its surface is covered by cylindrical 
epithelium. Here and there individual glands 
are seen extending down into the muscle, 
but at some points glands can be traced down 
by direct continuity for a distance of 2 cm. 
This appearance is found to represent noth- 



28 ADENOMYOMA OF THE UTERUS 

ing more than a dipping down of the normal 
glands. They are accompanied by characteristic stroma, and 
many of the glands are dilated. The epithelium lining those lying 
in the muscle has in many places fallen off and is lying free in the 
cavity of the glands. It looks as if the glands in the deeper portion 
were being forced out of existence and in the myomatous portion 
only fine remnants are visible. The stroma of the mucosa, however, 
in such areas still persists. The thickened portions of the uterine 
walls are composed of irregular bunches of non-striped muscle 
fibres cut longitudinally and transversely. They have a rich blood- 
supply and present the usual appearance. The large nodule situated 
in the fundus is composed of non-striated muscle fibres cut longi- 
tudinally and transversely. In many places this tissue has under- 
gone complete hyaline degeneration, and at some points this hyaline 
material has completely melted away, leaving small cavities. 

Diagnosis . — Diffuse myomatous thickening of the uterine 
walls; definite adenomyoma; general pelvic adhesions. 



CHAPTER II 

CASES OF ADENOMYOMA IN WHICH THE UTERUS RETAINS A 
RELATIVELY NORMAL CONTOUR— (Continued) 

Gyn. No. 2706. Path. No. 245. 

Multiple uterine myomata, commencing 
diffuse adenomyoma. Adenomyoma of the 
left uterine horn. Right hydrosalpinx; left 
tubo-ovarian cyst. 

M. A., white, aged forty-seven, married. Admitted April 6, 
1894; discharged May 12, 1894. The patient has been married 
twenty years. She has had no children and no miscarriages. The 
menses are regular, with a free flow and severe pain the first day. 
Since marriage the flow has lasted twice as long, is more profuse, 
and the pain is more severe. Moderate leucorrhcea at times. For 
over two years she has had pain in the left ovarian region, only 
constant for the past month. During that time there has been a 
continuous hemorrhage from the uterus, profuse at first, now less. 

Operation . — Hystero -myomectomy. Part of the growth 
was submucous and was removed through the vagina. After the 
operation the patient had persistent nausea and vomiting until the 
fourth day, when, after the vomiting of an ascaris lumbricoides, 
14 cm. long, the nausea and vomiting ceased. The maximum 
temperature was 100.5° F., on the third day. The patient made a 
satisfactory recovery. 

Path. No. 245 . — The specimen consists of the uterus, the 
dilated tube from the right side, and an ovarian cyst, together with 
the left tube and ovary. The uterus is 7 by 9 b}^ 5.5 cm. It has 
been amputated through the cervix. The peritoneal surface is 
smooth. On the right side about the middle of the fundus is a 
myomatous nodule, 1.5 cm. in diameter. At the junction of the 
left tube with the uterus is a myomatous nodule 1.5 cm. in diameter. 

29 



30 ADENOMYOMA OF THE UTERUS 

The uterine walls average 3 cm. in thickness. They contain three 
or four myomata, the largest 2 cm. in diameter. The uterine 
mucosa averages 2 mm. in thickness. 

Right side : The tube is 21 cm. long, .8 cm. in breadth, and dilated 
at the uterine end. After passing outward 6 cm. it becomes con- 
voluted and occluded. Behind this it forms a sac 5 by 6 cm. This 
somewhat resembles a pipe-bowl. On the surface are numerous 
adhesions. The ovary is 4 by 4 by 1 cm. The lower extremity 
is occupied by a cyst, 2 by 3 cm. 

The left side is for the most part occupied by a cyst, 13 by 12 by 
11 cm. It is smooth and glistening and traversed by numerous 
small vessels. Posterior^ there are many adhesions and a distinct 
sensation of fluctuation is perceptible. The tube is 17 cm. long, 
1.5 cm. broad. After passing outward 6 cm. it spreads over the 
surface of the tumor and finally merges into the tumor itself. The 
ovary is 5 by 3 by 1 cm. 

Histological Examination . — The cervical glands 
are normal. In the body of the uterus the mucosa is somewhat 
edematous. Some of the glands run parallel with, instead of at 
right angles to, the underlying muscle. As one approaches the 
fundus the mucosa reaches 5 mm. in thickness. The glands are very 
long. Their epithelium is intact. Some of the glands 
have extended down into the muscular layer. 
The stroma in places is infiltrated with small round cells, and in 
the deeper portions of the mucosa are a few lymphoid cells. The 
blood-vessels of the mucosa appear to be more numerous than 
usual and in places are dilated. 

The right cornu is normal. The left contains numerous cyst- 
like spaces, some of them situated on the side of the tube, others 
tying 2 to 4 mm. beneath the peritoneal surface. These glands 
are small and round or are irregular and dilated. They are lined 
with one layer of cylindrical epithelium, which in some places rises 
directly from the muscle. In other places it is surrounded by a 
faint amount of stroma similar to that of the uterine mucosa. The 
glands are dilated. The muscular tissue around these glands 



DIFFUSE ADENOMYOMA OF THE UTERUS 31 

presents a distinct myomatous appearance. One of the glands 
contains a little finger-like ingrowth. 

Diagnosis . — Multiple uterine myomata. Commencing dif- 
fuse adenomj^oma; adenomyoma of the left uterine horn; right 
hydrosalpinx; left tubo-ovarian cyst. 

Gyn. No. 3809. Path. No. 881. 

Discrete subperitoneal and interstitial 
uterine myomata. Commencing diffuse adeno- 
myomatous formation with the glajids orig- 
inating from the mucosa. General pelvic ad- 
hesions, probable remains of the Wolffian 
bodyintheleftovary. 

S. F., aged thirty-six, white. Admitted September 21, 1895; 
discharged October 19, 1895. The last period appeared two weeks 
ago; the flow was somewhat free and there was much pain. The 
bowels are constipated, defecation is painful. Micturition is scant 
and painful and at times it is necessary to catheterize. 

Operation . — Hystero-salpingo-oophorectomy. Considerable 
difficulty was experienced owing to the omental adhesions to 
the abdominal wall. The uterus was everywhere adherent. It was 
removed entirely. The highest temperature was 100.5° F., four 
days after the operation. The patient made an uninterrupted 
recovery. 

Path. No. 881 . — The specimen consists of the uterus with 
the appendages intact. The uterus is 7 by 6.5 by 6.5 cm.; it is 
covered by dense adhesions. On the posterior surface are two flat 
pedunculated nodules, 1.8 cm. in diameter. These are covered by 
adhesions. The uterine cavity is 4.5 cm. in length and 4 cm. in 
breadth. At the fundus the mucosa presents a slightly roughened, 
granular appearance, and projecting into the cavity from the lower 
third of the posterior wall is a myomatous nodule, 5 by 3 cm. The 
uterine mucosa averages 1 mm. or more in thickness. The uterine 
muscle averages 2.5 cm. in thickness. It contains several firm 
nodules averaging 1 cm. in diameter. On the right side the tube 



32 ADEXOMYOMA OF THE UTERUS 

is 5.5 cm. in length and varies from 5 to 8 mm. in thickness. Its 
surface is covered by a few adhesions and it contains a cyst 1.5 cm. 
in diameter, near the fimbriated end. The fimbriated extremity 
is patent and measures .8 cm. in diameter. It is also covered 
by adhesions. On pressure pus exudes from the fimbriated 
extremity. The ovary is normal in size, much mutilated, and 
covered by adhesions. 

Histological Examination . — The uterine mucosa 
has not been well preserved. The glands, where present, are normal 
and have an intact epithelium. The stroma of the mucosa shows 
a moderate amount of small round-cell infiltration and the uterine 
glands exhibit a peculiar tendency to extend 
a short distance into the muscle. Most of these 
are surrounded by normal stroma, but a few lie in direct continuity 
with the muscle. Sections through the nodules present a typical 
myomatous appearance. 

Right side: The tube presents the usual appearance, but the 
tube lumen contains a moderate amount of blood. Sections through 
the left cornu show that the epithelium in places is slightly swollen 
and that it has here and there cyst-like spaces which contain a few 
polymorphonuclear leucocytes and apparently some desquamated 
epithelial cells. Situated apparently in the hilum of the left ovary 
is an irregular, deeply staining area composed of irregular spindle- 
shaped cells which suggest connective tissue; and scattered through 
this tissue are irregular gland-like spaces, each of which is lined with 
one layer of cylindrical epithelium. The spindle-shaped cells are 
arranged in layers around the gland-like spaces. They are probably 
remains of the Wolffian body. 

In further sections through the adhesions on the posterior surface 
of the uterus, the uterine muscle just beneath the mucosa is seen to 
contain in some places one, in others three or four gland-like spaces. 
These are, however, slit-like in contour. They are lined with one 
layer of cylindrical epithelium in which cilia are in many places 
visible. These cavities are either empty or contain granular de- 
tritus, and here and there some desquamated epithelium. Some of 



DIFFUSE ADENOMYOMA OF THE UTERUS 33 

the glands lie in direct contact with the muscle. Others have a 
definite stroma surrounding them. This stroma is similar to that 
of the uterine mucosa. Around one of the glands the muscle is 
arranged in a circular manner. It looks as if it were forming a 
definite coat. 

Diagnosis . — General pelvic adhesions. Discrete sub- 
peritoneal and interstitial myomata. Commencing diffuse adeno- 
myoma; probable remains of the Wolffian body in the left ovary. 

Gyn. No. 9069. Path. No. 5229. 

Commencing diffuse adeno myoma of the 
uterus; slight pelvic peritonitis. 

M. M., aged thirty-five, white, married. Admitted September 17, 
1901; discharged October 2, 1901. Father, brother, and grand- 
father died of pulmonary tuberculosis. The patient has always 
been rather delicate and has had pneumonia three times. Her 
menses began at twelve, were regular, lasting two or three days; 
the flow was scant and painful. She has had a leucorrhoeal discharge 
since childhood. In 1897 the uterus was suspended. In 1899 she 
returned with a retroversion. This time she complained of more 
severe pain than she had had before the suspension was done. The 
most prominent symptoms were backache and frequency of urina- 
tion. There is no history of any severe hemorrhage. 

Operation .■ — Hystero-salpingo-oophorectomy. The patient 
made an uninterrupted recovery. 

Path. No. 5229 . — The specimen consists of the uterus, 
tubes, and ovaries. The uterus, including the cervix, is 5.5 by 4.5 
by 2.5 cm. Its peritoneum is smooth and glistening. At the fundus 
is a tag of tissue the result of the suspension of two years ago. The 
cervical canal appears as a transverse slit 5 mm. broad. The mucosa 
is exceedingly thin in the upper part of the cavity; it is granular 
and much congested. The appendages on both sides are covered 
with adhesions. 

The cervical mucosa is normal. Many of the glands, however, 

are much dilated. 
3 



34 ADENOMYOMA OF THE UTERUS 

Sections from the endometrium show the mucosa in places to 
be vety ragged, possibly the result of curettage. In other places 
the surface epithelium is intact. The stroma is slightly edematous. 
At some points the underlying muscle shows 
a distinct myomatous tendenc}^ and we have 
a direct extension of the glands into the un- 
derlying tissue, the picture presented being typical of 
adenomyoma. 

Diagnosis . — Pelvic peritonitis ; commencing adenomyoma ; 
small cyst of the ovary. 

Gyn. No. 7153. Path. No. 3429. 

Diffuse adenomyoma occupying the an- 
terior, posterior, and lateral uterine walls; 
in short, forming a mantle around the uterine 
cavity (Figs. 5, 6, 7). Slight pelvic peritonitis. 
Hysterectomy. Recovery. 

S. W., aged fifty-six, white, married. Admitted August 24, 
1899; discharged September 26, 1899. Complaint: pelvic tumor 
and hemorrhages from the uterus. The patient has been married 
thirty-four years, has had thirteen children; the youngest is thir- 
teen years of age. She has had one miscarriage. The menses 
commenced at thirteen, were regular, and lasted a week. For the 
last ten years they have been very profuse. Sometimes recently 
she would lose as much as a quart of blood. 

There has been a slight leucorrhceal discharge. The patient is 
very anaemic and presents a blanched appearance. She has a 
slightly intermittent pulse. The outlet is markedly relaxed and 
the vaginal walls are redundant. The cervix is in the axis of the 
vagina and points slightly to the right. It is about four or five 
times the normal size. The cervical lips are thin and rigid. The 
uterus is somewhat enlarged and irregular in outline. The lateral 
structures cannot be palpated. 

Operation August 28, 1899. — Hystero-salpingo- 
oophorectomy. The patient made a satisfactory recovery. 



DIFFUSE ADENOMYOMA OF THE UTERUS 



35 



Gyn.-Path. No. 3429 . — The specimen consists of 
the uterus with the appendages intact. The uterus is sUghtly 
enlarged. It has been amputated at the cervix. The body is 6 
cm. in length, 6 cm. in 
breadth, and 4.5 cm. in 
its antero-posterior di- 
ameter. The outer sur- 
face is covered with ad- 
hesions. These are especi- 
ally abundant over the 
fundus and posterior sur- 
face of the uterus. Both 
the anterior and 
posterior walls 
average 2.5 cm. 
in thickness and 
are readily di- 
visible into two 
zones. The inner 
consists of dense 
muscular tissue; 
the fibres run in 
and out in all di- 
rections and form 
definite whorls 
(Fig. 5). Situated in 
this diffuse growth are 
also a few small circum- 
scribed myomata. The 
coarse myomatous tissue 
extends directly to the mucosa, but apparently does not encroach 
upon it. At one or two points brownish areas, rather porous in 
appearance and faintly resembling uterine mucosa, are found in the 
myomatous tissue some distance from the mucosa. The outer 
portion of the uterine wall consists of normal muscle. This forms a 




Fig. 5. — Diffuse adexomyoma forming a complete 
ZONE AROUND THE UTERINE CAVITY. (Natural size.) 

Gyn. No. 3429. The figure represents an 
antero-posterior section through the entire uterus which 
has been amputated through the cervix. The uterine 
cavity is of the normal length and appearance and the 
mucosa is probably thinner than usual. The inner two- 
thirds of the muscular wall have been completely trans- 
formed into a diffuse myomatous tissue which extends to, 
but does not encroach upon, the uterine cavity. At a 
is a small cyst with a smooth inner lining. The outer 
portion of the uterine wall consists of perfectly normal 
muscle. Scattered throughout it are many cross-sections 
of small blood-vessels, well shown at b. Although the 
myomatous muscle sharply contrasts with the normal 
muscle, the two gradually merge into one another and 
are intimately blended. For the histological appearance 
see Figs. 6 and 7. 



36 ADENOMYOMA OF THE UTERUS 

covering vandng from 3 to 5 mm. in thickness and is sharply dif- 
ferentiated from the diffuse myoma. The uterine cavity is 5 cm. 
in length and at the fundus 4 cm. broad. The mucosa is perfectly 
smooth and is apparently not over 1 mm. in thickness. Just within 
the internal os, however, is a polypoid outgrowth, 1.2 by .6 by .4 cm. 

Right side: The tube is 10 cm. long and varies from 4 to 11 mm. 
in diameter. It is covered with vascular adhesions and its fimbriated 
extremity is occluded and adherent to the ovary. The ovary is 
senile in character; it measures 2.5 by 1.8 by 1.5 cm. and is covered 
with adhesions. 

Left side : The tube is 10 cm. in length and 5 mm. in diameter. 
Its fimbriated extremity is patent, but the fimbriae have here and 
there become agglutinated; the oyary is senile; it measures 3 by 
1.8 by 1.3 cm. 

Histological Examination . — Sections through the 
polyp near the internal os show that it is composed almost 
entirely of cervical tissue. The glands are abundant, and apart 
from being dilated offer little of interest. The mucosa lining the 
uterine cavity has for the most part an intact surface epithelium. 
This epithelium is low cylindrical in type. The uterine glands 
present the usual appearance and are lined with one layer of cylindri- 
cal epithelium. At numerous points the mucous membrane ex- 
tends directly into the underlying myomatous tissue (Figs. 6 and 7). 
Sometimes it is possible to trace it for a distance of 6 or 7 mm. 
The extension into the muscle varies in different places. At some 
points prolongations 4 or 5 mm. broad extend from the mucosa into 
the depth. At other points a large area of mucosa in the depth will 
communicate with the surface by an actual isthmus. The thickening 
of the anterior and posterior uterine walls is due to the presence of 
myomatous tissue. As was noted macroscopically, this forms a 
broad zone between the mucosa and the outer covering of normal 
muscle. The fibres of this myomatous tissue are particularly well 
preserved and wind in and out in all directions. Scattered 
everywhere throughout the myomatous zone 
are islands of mucous membrane identical 



DIFFUSE ADENOMYOMA OF THE UTERUS 37 



"S. . 



m 



.1 



^^^asa. 



f- 



\/ ^ 







■■^J 




■^^'^•^—i 

•■"^,■^'■•1'; 


% 


\ A'"^. 










' 'V 




P;^-,; 


"^ ^•'^ /" •'^^lW,'<^*'- 


"'''C^i'l^^^.^. 


,Jti^' J-' ■ ^^r 








■ - .. ■% ''.V • 






*■<*, 




;.=.,. 


"..- ,:,<M 


^- 1 


...■ ."-^^1 


;-• ' ' '■^. 


^-■vf i 


'- 


'f^ 


'«■•' 






"^''!\'^"'' 


^^' 


p--^^^^ 






Fig. 6. — Diffuse adenomyoma of the uterine wall with marked extension of the 
MUCOSA INTO THE GROWTH. (4 diameters.) 

Gyn.-Path. No. 3429. This is a section through the entire uterine wall in Fig. 5. 
a indicates the uterine mucosa; b, the outer covering of normal muscle. The intervening portion, 
comprising the major part of the uterine wall, consists of diffuse myomatous tissue. The uterine 
mucosa at a is of the normal thickness and presents the usual appearance. It is immediately 
noticeable that the surface is perfectly even, there being no tendency toward the formation of 
outgrowths. At c there is a wholesale extension of mucosa into the diffuse myoma. At c' and 
c" the mucosa can be traced for a considerable distance, but at c'" a most instructive picture is 
seen. Here we are able to follow the extension of the mucosa fully two-thirds of the way through 
the uterine wall and almost to the point where the diffuse growth ends and the normal muscle 
begins. It will be noted that the usual stroma accompanies the glands. At numerous other 
points, indicated by d, the mucosa is seen penetrating the myoma. Scattered throughout the 
diffuse growth are many islands of uterine mucosa containing anywhere from one to a dozen or 
more sections of glands embedded in the characteristic stroma. A few of the glands are dilated 
as shown at e. Here and there there are islands of stroma (/) devoid of glands. The glandular 
invasion in this case is remarkable, but it will be noted that no epithelial elements are found in the 
normal muscle. 



38 



ADENOMYOMA OF THE UTERUS 



with that lining the uterine cavity. Some of 
these are not more than 1 mm. in diameter; others much larger. 
Frequently they are cut lengthwise and can be traced for a distance 



r'.rsiiu^^. 



C- 

c- 




'"^Ml 



r^^^^eeKBrjii 



Fig. 7. — Extension* of the mucosa into a diffuse myoma of the uterus. (12 diameters.) 

Gyn.-Path. No. 3429. The section is from the body of the uterus represented 
in Fig. 5. A very low-power picture of this is seen in Fig. 6. a represents the thickness of the 
normal mucosa. The surface epithelium is intact and the surface of the mucosa is comparatively 
smooth. At b we have an angle where the lateral wall joins the top of the uterine cavity. The 
greater number of the uterine glands are normal in size, but a few are dilated. The normal 
mucosa is everywhere extending into the diffuse myoma, as indicated by c. The mucosa in the 
down-growths differs in no way from that lining the uterine cavity save for the fact that some of 
the glands, as seen at d, are dilated. This is another example of what we have many times 
reiterated, namely, that the mere extension of uterine glands into the muscle is not necessarily 
indicative of a malignant growth. 



of at least 1 cm. and, as was said before, near the mucosa their 
direct connection with the mucous me m b r a n e 
is established. The glands forming these islands can in 



DIFFUSE ADENOMYOMA OF THE UTERUS 39 

no way be differentiated from those of the mucous membrane. 
They are similar in shape and are Uned with one layer of the char- 
acteristic cylindrical ciliated epithelium. Surrounding these glands 
is the typical stroma of the mucosa. Some of the glands are dilated, 
and at least three or four of them reach a diameter of 2 mm. The 
epithelium of the dilated glands is somewhat flattened, stains palely, 
and the gland cavities contain desquamated epithelium. In one 
of the cavities two ill-defined giant cells are present, produced 
apparently by a coalescence of desquamated epithelium. Not 
infrequently are seen little islands of stroma staining deeply and 
having the characteristics of that of the uterine mucosa, lying in 
between muscle bundles. The outer covering of uterine muscle is 
perfectly normal. 

In this case it is possible to trace a definite relation between the 
islands of the mucosa and mj^omatous muscle. Where the mucosa 
is seen extending into the depth the mj^omatous fibres run parallel 
with the penetrating mucosa. Where this penetrating mucous 
membrane is cut transversely, we accordingly find the islands of 
mucous membrane surrounded by bundles of myomatous tissue 
also cut transversely. External to this zone we usually find a 
second in which the fibres run at right angles to the projection. 

This case is certainly a most interesting one. We have a fairly 
large uterine cavity and the inner two-thirds of the anterior, pos- 
terior and lateral walls are replaced by a diffuse myomatous growth. 
The underlying layers of the mucosa have penetrated this diffuse 
myoma in all directions, exactly in the same manner as roots enter 
the soil. Accordingly, at favorable points where we have obtained 
longitudinal sections we are able to trace a direct extension into the 
depth. At many points, however, these rootlets in the depth have 
been cut transversely, and are then recognized as isolated islands of 
mucous membrane surrovmded by m3^omatous tissue. Where the 
diffuse myoma ends, this extension of the mucosa into the depth 
ceases and the entire myoma is covered with a layer of normal 
uterine muscle. This growth is without a doubt benign in character. 
The appendages offer nothing of interest. 



40 ADENOMYOMA OF THE UTERUS / 

Diagnosis . — Diffuse adenomyoma occupying the anterior, 

posterior, and lateral uterine walls; slight pelvic peritonitis. 

I 

/ 
Path. No. 8760. 

Diffuse adenomyoma of the body of the 
uterus with the glands originating from the 
uterine mucosa. 

A. H. Operated upon at the Church Home on June 9, 1905. 
Operation: complete hysterectomy. The specimen consists of the 
entire uterus with the tubes and ovaries attached, and there is also 
a portion of the vaginal mucosa. The uterus measures 9 b}^ 5 by 
4 cm. Its anterior surf ace is normal ; its posterior slightly irregular, 
owing to the presence of two small myomatous nodules averaging 
1 cm. in diameter. These project a few millimetres from the surface. 
The uterine walls vary from 1.5 to 2.5 cm. in thickness. The 
uterine mucosa appears normal except for the presence of a polyp, 
which for .3 cm. projects into the cavity from the posterior wall. 

Right side : The tube contains two ostia. The right ovary con- 
tains a small cyst. The left appendages are normal. 

Histological Examination . — Sections from the 
uterine mucosa show an intact surface epithelium. Manj^ of the 
glands are dilated and the stroma generall}^ appears normal. I n 
numerous places the glands with their ac- 
companying stroma can be traced directly 
into the muscular tissue. The muscle shows diffuse 
myomatous transformation. Some of the glands in the myomatous 
areas are markedly dilated. Isolated gland spaces are found scat- 
tered throughout the diffuse myomatous tissue, but none are visible 
in the neighborhood of the peritoneal surface. 

Diagnosis . — Diffuse adenomyoma of the body of the 
uterus; normal tubes and ovaries. 

H. A. K. Sanitarium No. 2144. Path. No. 9705. 
Diffuse adenomyoma involving the entire 
body of the uterus with the glands distinctly 



DIFFUSE ADENOMYOMA OF THE UTERUS 41 

rising from the mucosa; slight endometritis; 
discrete interstitial myomata. 

F. M. R., white, aged thirty-nine, married. Admitted April 6, 
1906; discharged May 22, 1906. The patient has had no children, 
no miscarriages. She entered complaining of dysmenorrhcea, free 
uterine hemorrhage, and some leucorrhoea. On admission her 
haemoglobin was 70 per cent. 

Operation . — Hj^stero-myomectomy. The patient made an 
uneventful recovery. Her highest post-operative temperature was 
101.6° F., twenty-four hours after operation. 

Path. No. 9705 . — The specimen consists of the uterus, 
considerably enlarged, which has been amputated through the cervix. 
It is 10 cm. in length, 10 cm. in breadth, and 17 cm. in its antero- 
posterior diameter. Situated in the anterior wall is a myoma 3 cm. 
in diameter. The posterior wall varies from 2.5 to 4.5 cm. in thick- 
ness; the anterior wall from 2 to 2.5 cm. The increase in thickness 
is due to a diffuse myomatous transformation of the posterior wall, 
which is also present in the anterior wall. 

Sections from the endometrium show that the surface epithelium 
is intact. The mucosa in the superficial portion shows typical 
gland h}' per trophy and there is a great deal of small round-cell 
and polymorphonuclear cell infiltration, giving a picture of subacute 
endometritis. The mucosa in the deeper layers is perfectly normal 
and can be followed directly into the myomatous tissue. Scat- 
tered throughout the anterior and posterior 
walls everywhere are large and small islands 
of uterine mucosa. The glands are normal. The diffuse 
myomatous tissue is everywhere riddled with islands of mucosa, 
some of them 2 mm. in length, and in one section it is sometimes 
possible to make out thirty or more islands of mucosa scattered 
throughout the myoma. 

Diagnosis . — Diffuse adenomyoma involving the entire 
body of the uterus with the glands distinctly arising from the mucosa ; 
slight endometritis. Discrete interstitial myomata. 



42 



ADENOMYOMA OF THE UTERUS 



Gyn. No. 2754. Path. No, 
Diffuse a d e n o m y o m a of t 




Fig. 8. — Diffuse adenomyoma of the anterior uterine 
WALL. (Natural size.) 

Gyn. -Path. No. 290. This is an antero-pos- 
terior section of the uterus. The organ has been amputated 
through the cervix. The anterior hp of the cervix is consider- 
ably thickened. The anterior uterine wall is increased in thick- 
ness. It is covered externally with a zone of normal mus- 
cle, but the major portion of the thickening is composed of 
a diflfuse myomatous growth which has encroached to a marked 
degree on the uterine cavity. In this diffuse myoma several 
small discrete myomata are visible. A few of the cervical 
glands are dilated and lying in the cervical canal is a polyp. 
The uterine cavity is considerably lengthened. The mucosa of 
the anterior wall is of the usual thickness, but at numerous 
points it can be seen penetrating the diffuse myoma for a short 
distance. The posterior wall is relatively normal, but at a 
contains a submucous myoma. Attached to the uterus 
is the proximal end of the right tube. For the histological 
picture of the diffuse growth in the anterior wall see Figs. 
9 and 10. 



290. 

he uterine wall 
(Figs. 8, 9, and 10). 
Hysterectomy ; 
Recovery. 

R.M., married, aged 
fifty-four. Admitted 
May 2, discharged June 
5, 1894. The menses 
commenced at eigh- 
teen, were regular, pro- 
fuse but painless. Five 
months ago the men- 
strual flow became pro- 
fuse and lasted much 
longer, with flooding 
each month. 

The patient has 
been married thirty- 
two years and has had 
ten children and one 
miscarriage. After the 
third labor there was 
puerperal fever. At 
present she complains 
of a dull aching pain in 
the right lower abdo- 
men. On examination 
the left side of the pel- 
vis is found filled with 
a mass which cannot 
be differentiated from 
the uterus. It is firm, 
sensitive, and immo- 
bile. 



DIFFUSE ADENOMYOMA OF THE UTERUS 



43 



Operation. — Vaginal hystero-myomectomy. Double sal- 
pingo-oophorectomy. The base of the bladder was opened for 



rials' 



g«ra!S5i-.:4^1w5i 



^. f 



, ,^ -i^' '^^ 



^sae 



a--: 




c h 
Fig. 9. — Diffuse adenomyoma of the anterior uterine wall. (2i diameters.) 

Gyn.-Path. No. 290. This is a section through the anterior uterine wall in Fig. 
8. Almost the entire wall consists of diffuse myomatous tissue, but at the points indicated by a 
three discrete nodules are visible, and between these and the mucosa is a fourth one. b represents 
the usual thickness of the mucosa, and it will be seen that it is normal. In many places, as indi- 
cated by c, the mucosa is seen extending into the myoma and there sending off numerous secondary 
branches. At d is an island of mucosa situated deep in the muscle, but showing at several points 
continuity with the mucosa lining the uterine cavity. Scattered throughout the inner half of 
the uterine walls are glands occurring in bunches or singly. They are invariably surrounded by 
dark zones which represent normal stroma of the mucosa. The glands can be traced as far out- 
ward as e. f represents a tear in the specimen. It is clear that the glands in this diffuse adeno- 
myoma have originated from the uterine mucosa. 

4 cm. during the operation. It was sutured. After the operation 
the patient complained of pain in the bladder for several days and 
passed some pus. 

Gyn.-Path. No. 290 . — The specimen consists of the 



44 



ADENOMYOMA OF THE UTERUS 




M 





— -i 



H:B^ehe2'. 



Fig. 10. — Mode of extension of uterine 
glands into a diffuse adenomyoma. 
(10 diameters.) 

Gyn.-Path. No. 290. The sec- 
tion is from the diffuse adenomyoma in the an- 
terior wall of the uterus in Fig. 8. a is a por- 
tion of the normal uterine mucosa. The super- 
ficial layers have accidentally been removed by 
mechanical injury. The mucosa can be traced 
by direct continuity to a' . It will be seen that 
the glands, apart from some dilatation, are per- 
fectly normal, and that they are accompanied 
by the stroma of the mucosa, h is an island 
of stroma containing one uterine gland. This 
stroma can be traced upward nearly to the sur- 
face, downward as far as c. The irregularity in 
its course is undoubtedly due to the unequal 
pressure of the ever-growing diffuse myoma. 
d is an island of stroma devoid of glands; e, an- 
other point where the mucosa is penetrating 
the myoma. 



uterus, tubes, and ovaries intact. 
The uterus is 12 cm. long, 7 cm. 
broad, and 6.5 cm. in the antero- 
posterior diameter. Both ante- 
riorly and posteriorly it is smooth 
and glistening. The cervix is 4 
cm. in diameter. The posterior 
uterine wall is about 2.5 cm. in 
thickness and somewhat striated. 
It contains a submucous myoma, 
2.5 cm. in diameter. The an- 
terior wall near the cervix is 2 
cm. in thickness, but rapidly be- 
comes thicker and forms a diffuse 
growth 3.5 cm. thick (Fig. 8). 
This encroaches to a consider- 
able extent on the uterine cavity. 
It presents a very coarse striation 
resembling a diffuse myoma, and 
scattered throughout it are sev- 
eral well-defined myomata, vary- 
ing from 2 to 6 mm. in diameter. 
The cervical mucosa presents the 
usual appearance. The uterine 
cavity is 6.5 cm. long and its 
mucosa, which is intact, is ap- 
parently 1 mm. in thickness. 

Right side: The tube is 
normal in size but covered by 
numerous adhesions. The ovary 
is unaltered. 

Left side : The tube and ovary 
seem to be normal. 

Histological Exam- 
ination . — The cervical glands 



DIFFUSE ADENOMYOMA OF THE UTERUS 45 

are normal. The uterine mucosa is about 1 mm. in thickness; 
its surface epitheUum is intact, but is low cylindrical or cuboidal 
in character. The glands are few in number and are here and there 
slightly dilated. The gland epithelium is low cylindrical in type 
and is intact. The stroma of the mucosa is somewhat lax and is 
made up of cells having elongated or oval nuclei which are separated 
from each other by red corpuscles and large vacuolated spaces. In 
other words, the tissue of the stroma is edematous, more especially 
in the superficial portions. The diffuse thickening in the posterior 
wall is due to a myomatous transformation of the uterine muscle, 
with here and there the development of young circumscribed myo- 
mata. Where the diffuse myoma is present in 
the anterior wall the uterine mucosa is found 
extending into the depth at many points, 
and in some places direct continuity with 
the surface can be traced for a distance of 
1.2 cm. (Fig. 9). Often the mucosa is recognized as islands of 
mucous membrane far down in the myomatous tissue and completely 
surrounded by it. The mucosa throughout the myoma differs in 
no way from that lining the uterine cavity. The glands are identical 
with those of the mucosa and are surrounded by the typical stroma 
(Fig. 10). The picture then represents a diffuse adenomyoma of 
the anterior uterine wall extending almost to the peritoneal surface. 
That the gland elements are derived from the uterine mucosa is 
evident. Histological examination of the tubes shows that they 
are very slightly altered. 

Diagnosis . — Diffuse adenomyoma of the anterior uterine 
wall with the presence of a few small circumscribed myomata. 
Right side: Slight perisalpingitis; normal ovary. Leftside: Normal 
appendages. 

Gyn. No. 12,080. Path. No. 8715. 
Chronic endometritis; diffuse adenomy- 
oma of the uterine walls with direct exten- 
sion of the mucosa into the depth, acute puru- 



46 ADENOMYOMA OF THE UTERUS 

lent and chronic salpingitis; general pelvic 
adhesions. 

E. B., aged thirty, colored, married. Admitted April 28, 1905; 
discharged June 17, 1905. Complaint: pain in the lower part of 
abdomen. Her menses began at twelve, were not painful, lasting 
several days. Her periods of late have increased in duration; the 
last one continued for fourteen days. She has been married thirteen 
years and has had six children, no miscarriages. The youngest 
child is seven months old. Deliveries normal. On April 12, 1905, 
the menstrual flow began and appeared to be normal, but on the 
fourteenth day the patient suddenly felt very weak, and on April 
17th, while doing her washing, she felt a sudden severe bearing- 
down pain in the lower abdomen, especially on the right side. The 
pain was not constant, but occurred every few minutes. Numerous 
clots were passed at this time, and the pain became so severe that 
the patient was forced to come to the hospital for relief. 

Note of May 22d : This patient has been in the hospital two weeks. 
On admission she apparently had peritonitis, and it was deemed 
wiser to delay operation for a time. At operation a large pus tube 
was found on the right side. This curved over the surface of an 
ovarian cyst and passed down into the cul-de-sac behind the uterus. 
On the left side a large pus tube could be seen winding out to the 
pelvic wall. This curved back into the depth. The rectum was 
adherent to the base of the broad ligament on the left side and also 
to the posterior surface of the uterus. The upper three-fourths of 
the uterus was free from adhesions, but below this point the organ 
was firmly fixed. The uterus was removed with a great deal of 
difhculty. 

After operation the patient showed signs of shock, but gradually 
improved, and was discharged on June 17, 1905. Her temperature on 
admission was 101° F., ran a regular course, reaching its highest point, 
102.2° F., on June 2d. From this time it gradually dropped. 

Path. No. 8715 . — -The specimen consists of the uterus, 
which is 6 by 6 by 5 cm. and covered with many adhesions, espe- 
cially posteriorly. The uterine walls show considerable thickening. 



DIFFUSE ADENOMYOMA OF THE UTERUS 47 

On examination of the slide with the naked 
eye it is possible to trace the uterine mucosa 
for 4 mm. into the depth by direct continuitj^. 
The mucosa has an intact surface epithelium. This, however, is 
swollen and the underlying tissue shows a great deal of small round- 
cell infiltration, especially in the superficial layers. There has been 
a chronic endometritis. The glands in the deeper layers are perfectly 
normal. At the junction of the mucosa with the muscle, glands 
are seen penetrating into the depth. Examination of further 
sections shows practically the same appearance of the mucosa. 
There are dome-like projections which extend directly into the 
muscle for a long distance, then split up into branches. 

Sections from the tube show a chronic pyosalpingitis. 

Diagnosis . — Chronic endometritis, diffuse adenomyoma of 
the uterine walls with the glands coming from the mucosa ; acute 
purulent and chronic salpingitis. 

Gyn. No. 2806. Path. No. 334. 

Diffuse adenomyoma of the uterine wall 
(Figs. 11 and 12). Interstitial and subperitoneal 
myomata, general pelvic peritonitis. Right 
side, tubo-ovarian abscess. Left side, healed 
salpingitis. Hysterectomy. Recovery. 

M. G., widow, white. Admitted May 30; discharged July 12, 
1894. The patient entered the hospital in October, 1893, when a 
diagnosis of myomatous uterus was made, but operation was not 
advised at that time. Since then the patient has felt well until 
two and a half months ago, when she had a feeling of " her womb 
being out of position," followed in one month by an acute attack of 
pain in the lower abdomen. Since then this pain has been constant. 
She has also had chilty sensations accompanied by sweating. 

Operation . — June 14, 1894. Hystero-myomectomy. Dou- 
ble salpingo-oophorectomy. The myomatous uterus was densely 
adherent to the pelvis. There was an abscess involving the left 
tube and ovary. This abscess contained 150 c.c. of thick, creamy, 



'48 



ADENOMYOMA OF THE UTERUS 



sterile pus. The omentum and vermiform appendix were adherent 
to the rectum. The patient had much nausea and abdominal pain 
after operation, and there was great nervousness, and at times a 
certain degree of delirium. 

Gyn.-Path. No. 334 . — The specimen consists of a 

moderately enlarged uterus 
with adherent appendages. The 
uterus is 8 by 7 by 7 cm. ; it is 
bright red in color and every- 
where covered with dense vas- 
cular adhesions. On its anterior 
surface are two myoma'ta, the 
one 2.5 cm., the other 1.5 cm. 
in diameter. On section the 
cervical mucous membrane 
presents the usual appearance. 
The anterior uterine wall aver- 
ages 2 cm. in thickness, the 
posterior slightly less. Situ- 
ated in the fundus are several 
small myoma ta (Fig. 11). One 
of these encroaches slightly 
upon the uterine cavity. At 
the junction of the cervix with 
the body is another myoma 1.5 
cm. in diameter, and scattered 
throughout the walls are several 
minute myomata. The uterine 
cavity is 2.5 cm. in length and 
the mucosa is scarcely more 
than 1 mm. in thickness. Right side : The tube is 17 cm. in length, 
densely adherent to the ovary, and reaches 2.5 cm. in thickness. It is 
filled with pus. The ovary is considerably enlarged, somewhat cystic, 
and is the seat of an abscess which communicates with the tube. Left 
side : The tube and ovary form a densely adherent mass 5 by 3 cm. 




Fig. 11. — Diffuse adexomyoma of the uterus 

WITH SEVERAL DISCRETE MYOMATA. (Natural 

size.) 

Gyn.-Path. No. 334. This is 
an antero-posterior section of the uterus and to 
one side of the median line, as we are only able 
to see portions of the uterine cavity a and a' . 
Situated in the anterior wall and fundus are 
six myomata, and in the posterior wall near 
the cervix there is a small interstitial nodule. 
Both uterine walls show a rather coarse arrange- 
ment of the muscle and the posterior wall is 
somewhat thickened. The uterine mucosa as 
seen at a is of the normal thickness and appears 
to be unaltered. For the histological picture 
see Fig. 12. 



DIFFUSE ADENOMYOMA OF THE UTERUS 



49 



Histological Examination . — The rioht tube 



IS 



The left tube also shows an 






X__0-. A '^'.. 






:^ 



•^'^ \v: 



n.- 






"'k 



c-1 



seen to be the seat of a salpingitis 
inflammatory process, but 
partial healing has taken 
place. 

The chief interest lies in 
the condition of the uterine 
mucosa. The surface epithe- 
lium has disappeared, evi- 
dently owing to mechanical 
removal. The glands are 
somewhat degenerated, prob- 
ably owing to faulty harden- 
ing. Where preserved, they 
present the usual appearance. 
In places there is small round- 
cell infiltration. The stroma 
as a whole presents a wavy 
appearance. Its cells have 
spindle-shaped nuclei which 
closely resemble those of 
the normal muscle. They 
also run in definite bun- 
dles. They, however, stain 
more deeply. At some 
points isolated glands 
or bunches of glands 
are seen extending; 
down into the mus- 
c 1 6 (Fig. 12). These glands 
present the usual appearance 
and most of them are sur- 
rounded by stroma. A few, however, lie in direct contact with the 
muscle bundles. Down in the depth the muscle is gathered up into 
irregular bundles and presents the characteristic myomatous appear- 



i^^^e^^<^ £:S&ti^> 



t 



1 



Fig. 



12. — Diffuse adenomyoma of the poste- 
rior UTERINE WALL. (10 diameters.) 

Gyn.-Path. No. 334. The section 
is from the posterior wall in Fig. No. 11. a repre- 
sents the uterine mucosa; owing to imperfect harden- 
ing, the surface epithelium is wanting. The glands 
and stroma are, however, perfectly normal. The 
uterine walls are composed of myomatous muscle. 
At a' the mucosa is seen penetrating the muscle, 
and scattered throughout the deeper portions are 
cross-sections and longitudinal sections of glands. 
These are surrounded by stroma separating them 
from the muscle. At h the stroma around the gland 
seems to be sending off prolongations in all direc- 
tions. The dark areas c and c' are also areas of 
stroma, but are devoid of glands. 



50 ADENOMYOMA OF THE UTERUS 

ance. Here also glands are present, in places surrounded by the 
characteristic uterine stroma. These glands are found at a distance 
of at least 1 cm. from the uterine cavity. We have, then, in this 
uterus faint evidences of an old endometritis and diffuse myomatous 
transformation of the uterine wall, with extension of the uterine 
glands into this myomatous tissue, especially in the posterior wall. 
As was noted, there are also well-defined subperitoneal and inter- 
stitial myomata. 

Diagnosis . — Subperitoneal and interstitial uterine myo- 
mata; diffuse adenomyoma of the uterine wall; general pelvic 
peritonitis; right side, tubo-ovarian abscess; left side, partially 
healed salpingitis. 

Gyn. No. 3204. Path. No. 526. 

Edema of the uterine mucosa; commencing 
adenomyoma in the body, the gland elements 
coming from the mucosa; general pelvic ad- 
hesions; small ovarian cyst. 

M. S., married, aged thirty-six, colored. Admitted November 22, 
1894; discharged January 15, 1895. The menses began at four- 
teen; flow regular, lasting from three to five days. On November 
11th her last period was accompanied by severe pain. The patient 
has been married eleven years and has had two children and prob- 
ably one miscarriage. Following this there seems to have been 
puerperal sepsis. 

Operation . — Hystero-salpingo- oophorectomy. The patient's 
temperature after operation was 101.5° F. It gradually fell, but on 
the sixteenth day there was another rise to 101.6° F. The pulse 
immediately after the operation, which was exceedingly difficult, 
was 145, but gradually fell to normal. 

Path. No. 526 . — The specimen consists of the uterus 
with tubo-ovarian masses on either side. The uterus measures 
7 by 5 by 5 cm. Its anterior surface is smooth and glistening. 
Posteriorly it is fastened to the masses on either side by broad 
vascular adhesions. The under cut surface is 2 cm. in diameter. 



DIFFUSE ADENOMYOMA OF THE UTERUS 51 

The cervical mucosa is pale and glistening. The uterine walls 
average 2 mm. in thickness and are pinkish-white in color and slightly 
striated. The uterine cavity is 5 cm. long; at the fundus it is 2.5 
cm. in breadth. The mucosa in the lower part is yellowish-white, 
smooth and glistening, but in the fundus presents numerous patches 
of ecchymosis. It varies from 3 to 5 mm. in thickness. 

Histological Examination . — The uterine mucosa 
in the vicinity of the external os shows small round-cell infiltration, 
but otherwise is normal. In the upper part of the uterus the mucosa 
is considerably thickened. The surface epithelium is intact. The 
glands are tortuous and abundant. The stroma in the superficial 
portion is very edematous, but in the deeper portion it is normal. 
With the low power the mucosa at many points 
is seen extending down into the depth and 
constrictions are forming, almost cutting 
off some areas from the uterine mucosa. This 
can be traced in many places for at least 2 to 3 mm. Some of the 
glands are dilated, but the majority are perfectly normal. The 
uterine muscle, chiefly beneath the mucosa, is being divided up into 
whorls; in other words, the appearances suggest myomatous tissue. 
Where the glands extend into the depth, they are usually surrounded 
by stroma, but in some places lie in direct contact with the muscle. 

On the right side there are numerous adhesions, and there is a 
unilocular ovarian cyst, probably a dilated Graafian follicle. On 
the left side is a unilocular cyst, also probably a Graafian follicle. 
There are general pelvic adhesions. 

Diagnosis . — Edema of the mucosa ; early diffuse adeno- 
myoma of the body of the uterus; pelvic adhesions with small 
bilateral ovarian cysts. 



CHAPTER III 

CASES OF ADENOMYOMA IN WHICH THE UTERUS RETAINS A RELA- 
TIVELY NORMAL CONTOUR— (Continued) 

Gyn. No. 3192. Path. No. 525. 

Commencing diffuse adenomyoma. Adeno- 
myoma of the left uterine horn. 

M. D., white, aged forty-five, married. Admitted November 
19, 1894; discharged December 15, 1894. Complaint: Pain in 
the lower abdomen. The patient has had frequent attacks of 
malaria, but otherwise has been perfectly healthy. Her menses 
began at nineteen and were regular, lasting two or three days. For 
the past year, however, the periods have occurred every three weeks, 
and there has been considerable pain for three days preceding the 
onset of the flow. The last period came on three weeks ago. The 
patient states that there has been frequent pain and a thin white 
but not copious discharge. She has been married twice, the first 
time twenty-four years ago; the second time two years ago. She 
has had five children. She had a miscarriage at the second month 
eleven years ago. For the past year the patient has complained 
of rather severe and persistent backache and pain extending down- 
ward and reflected to both lower limbs. Walking or any exertion 
has caused an aggravation of this pain. The patient appears to 
be debilitated and is pale. Her appetite is poor. 

Operation .- — Hystero-salpingo-oophorectomy. The uterus 
was enlarged and on attempting to separate the adhesions 
the bleeding was somewhat profuse. Convalescence was uninter- 
rupted and the patient was discharged on December 15th. The 
highest post-operative temperature was 100.5° F. 

Path. No. 525 . — The specimen consists of the uterus, 
tubes and ovaries intact. The portion of the uterus present measures 
6.5 by 7 by 6 cm. The anterior surface over its lower half is smooth 

52 



DIFFUSE ADENOMYOMA OF THE UTERUS 53 

and glistening. The upper portion of the anterior surface and the 
posterior surface are covered with rich vascular adhesions. The 
uterine muscle averages 2.8 cm. in thickness and is grayish-pink in 
color and has numerous vessels scattered throughout its walls. 
The largest of these is 2 mm. in diameter. The uterine cavity is 
3.2 cm. long, but at the fundus 4 cm. broad. The mucosa is 
glistening, somewhat translucent, but on the left side presents a 
large patch of ecchymosis. 

On the right side the tube at the uterine cornu measures 6 mm. 
in diameter. After passing outward 3 cm. it merges into a tubo- 
ovarian mass 5 by 4 by 1.5 cm. This is too mutilated for description. 
On the left side the tube is 8 cm. long, 5 mm. in diameter at the 
uterine extremity. The fimbriated end is occluded; it measures 
1.5 cm. in diameter. This tube is free from adhesions. In the 
outer end of the parovarium is a thin-walled cyst, 2 cm. in diameter. 
This is covered with peritoneum which can be readily shelled off. 
It is seen to be intimately connected with the parovarium. The 
ovary is 3 by 3 cm. and much mutilated. 

Histological Examination . — The uterine mucosa 
varies from 3.4 to 5 mm. in. thickness. The surface epithelium is 
intact but somewhat swollen. The glands are abundant and some- 
what tortuous. In a few places they are dilated. The lumina of 
the glands contain a small amount of granular material. The 
glands extend downward into the muscle at 
numerous points. Most of these are surrounded by stroma. 
A few, however, lie between muscle bundles. The stroma of the 
mucosa in the superficial portion is lax, but scattered everywhere 
throughout it are lymphoid cells with here and there a few poly- 
morphonuclear leucocytes. In many places are clear spaces filled 
with a homogeneous substance which stains with eosin. The uterine 
muscle near the mucosa is being divided up into myomatous bundles, 
and we are able to trace the mucosa for a considerable distance into 
the depth. Just beneath such areas we find isolated glands and 
glands surrounded by their normal stroma. There is no doubt that 
we are dealing with a commencing adenomyoma. 



54 ADENOMYOMA OF THE UTERUS 

Examination of the left uterine horn shows numerous gland-like 
spaces just beneath the cross-section of the tube. These in many 
places show evidence of communicating with one another. The 
majority of them are irregular and are lined with cuboidal epithelium. 
The epithelial cells lie in direct contact with the muscle. At other 
points, however, the epithelium is separated from the muscle by a 
faint amount of stroma. In this case we also have a gland-like 
space lying just beneath the peritoneal adhesions. This space is 
surrounded by muscle and has a lining of one layer of cylindrical 
epithelium. 

Diagnosis . — Diffuse adenomyoma of the uterus ; adeno- 
myoma of the left uterine horn. 

Gyn. No. 5768. Path. No. 2066. 

Adenomyoma occupying both the anterior 
and posterior uterine walls; in other words, 
forming a complete zone around the uterine 
cavity (Figs. 13, 14, 15, and 16). Hysterectomy. 
Recovery. 

J. W., single, aged thirty-eight, white. Admitted January 3; 
discharged January 31, 1898. The menses commenced at fifteen, 
were regular, copious, and accompanied by many clots. The 
patient has had severe dysmenorrhcea as long as she can remember, 
this being more pronounced during the first three days of the flow. 
She has had a rather profuse leucorrhceal discharge, occasionally 
yellowish-red in color. The bowels are constipated. Micturition 
is frequent and burning and she has pain in the lower abdomen, 
especially on the left side, which is particularly severe at the men- 
strual period. 

The outlet is intact, the uterus about 7 cm. in diameter, regular, 
hard and smooth. 

Operation Jan. 5, 1898 . — Hystero-myomectomy. 
The right ovary was left in situ. The highest post-operative tem- 
perature was 100.6° F. The pulse did not rise above 92. She made 
an excellent recovery. 



DIFFUSE ADENOMYOMA OF THE UTERUS 



55 



Gyn.-Path. No. 2066 . — The specimen consists of a 
pear-shaped uterus, considerably enlarged. This has been amputated 
at the cervix; it measures 8 cm. in length, 9 cm. in breadth, and 8 




Uterine cav. 

Fig. 13. — Diffuse adenomyoma of the uterus involving the anterior and posterior 
WALLS AND FUNDUS. (| natural size.) 

Gyn.-Path. No. 2066. The uterus has been amputated through the cervix. 
Almost the entire body has been transformed into a diffuse myomatous growth represented by 
several large coarse bands of fibres with many smaller bands passing off from them and winding 
in every conceivable direction. The thickening is most marked in the anterior wall, where the 
growth extends almost to the peritoneal surface. There is, however, a thin muscular covering, 
as indicated bye. The lower margin of the growth in the anterior wall is indicated by a. In the 
posterior wall the growth extends downward to b. The entire growth, although well defined, is inti- 
mately blended with the normal muscle. The uterine cavity is of the normal length and, although 
there are a few inequalities in the surface of the mucosa, it is comparatively regular and of normal 
thickness. Fig. 14, from a section through the entire body of the uterus, illustrates the structure 
as seen with the low magnification. The finer details are shown in Figs. 15 and 16. Clinically 
a bimanual examination of this uterus would show a moderately enlarged, globular, but smooth, 
firm fundus. No clue would be gained from introducing a sound into the uterine cavity. 

cm. in its antero-posterior diameter. It is perfectly smooth, but 
has a rather uneven surface. On section the uterine cavity is found 
to be 6 cm. in length. It is recognized as a narrow slit (Fig. 13). 
Its mucosa is of the normal thickness and seems unaltered. The 



56 



ADENOMYOMA OF THE UTERUS 



^H 



U 




I 



-^> 






'?\. 






V 






y 



increase in size of the uterus is 
due to a diffuse thickening of 
its walls. This is general, but 
more prominent in the ante- 
rior than in the posterior wall. 
The anterior wall varies from 
4 to 5 cm. in thickness, the 
posterior from 3 to 3.5 cm. 
This diffuse thickening which 
is found in both uterine walls 
consists for the most part of 
myomatous tissue. Glistening 
bands are found running in 
and out in all directions and 
forming definite whorls. Scat- 






p 




%^-^ 



^ 



1' 



\ 









'^: 



-est.- 



^^/ 



./■ 






■^■«.r> 



Fig. 14. — Diffuse adenomyoma of the 
anterior and posterior uterine 
WALLS. (3 diameters.) 

Gyn.-Path. No. 2066. This 
is an antero-posterior section through the 
entire thickness of the uterus in Fig. 13. 
It is, however, taken nearer the side, hence 
only a small portion of the uterine cavity 
(a) is seen. At this level the anterior and 
posterior walls are practically of equal 
thickness. The myomatous transforma- 
tion of the muscle is hardly recognizable 
with this power. At b the uterine mucosa 
is of the normal thickness, but at c can be 
seen penetrating the surrounding muscle. 
At c' it can be followed for quite a distance. 
The mucosa penetrates en masse, carrying 
with it the normal stroma. Scattered 
throughout both walls, but more par- 
ticularly the anterior, are bunches of mu- 
cosa. These are well shown at d and at d'. 
We can trace the mucosa in its windings 
for a considerable distance. A goodly num- 
ber of isolated glands or glands in small 
bunches are distributed throughout the 
walls. At e are several dilated glands 
with little or no intervening stroma separ- 
ating them from the muscle. / is a dis- 
crete myomatous nodule. It is clearly evident that the glands in this diffuse myoma are due to 
down-growths from the mucosa. (For the finer structures of the adenomyoma see Figs. 15 and 16.) 



fii. 



X. 



v.. 



**t 



<? 



^/ 



> 






V 



V 



^^l 



DIFFUSE ADENOMYOMA OF THE UTERUS 



57 



tered everywhere throughout the growth are minute, cyst-Uke spaces 
varying from a pin-point to 2 mm. in diameter. 

-The uterine mucosa 



Histological Examination 

















,.iL 



^, 



■.Ci. 



.■Q: 






Fig. 15. — Method of penetration of the mucosa in a diffuse adenomyoma of the uterine 

WALL. (8 diameters.) 

Gyn.-Path. No. 2066. The section is from the body of the uterus in Fig. 13. 
a represents the thickness of the uterine mucosa. The surface epithehum has been mechanically 
lost except over the small area indicated by b. The uterine glands are perfectly normal. At 
three points, however, the mucosa can be seen extending into the underlying myomatous tissue. 
This is especially well marked at c, where a large mass of the normal mucosa is flowing into the 
growth. It can be traced to the lower margin of the section at c'. At d we have an island of 
mucosa which can be traced upward to d'; in other words, almost to the mucosa. The island 
of mucosa (e) resembles in every particular that lining the uterine cavity. Here and there a 
gland shows some dilatation. 



has an intact surface epithelium which presents the usual appearance 
(Figs. 14 and 16). The uterine glands are somewhat convoluted, 
slightly branching, and are lined with one layer of cylindrical 



58 



ADENOMYOMA OF THE UTERUS 




Fig. 16. 



DIFFUSE ADENOMYOMA OF THE UTERUS 59 

epithelium. The stroma of the mucosa is normal and here and there 
are a few small round cells. At many points a most striking picture 
is noted. The mucosa extends down into the underlying muscle 
for a distance of 1 cm. or more, and at such points the glands are 
perfectly normal and are surrounded by the characteristic stroma 
of the mucosa (Figs. 14, 15, and 16). It looks as if the mucosa were 
just falling down quietly into the clefts between muscle bundles. 
The diffuse thickening in the uterine wall is due to a myomatous 
transformation of the muscle, with here and there the formation 
of a small, sharply circumscribed myoma. Scattered everywhere 
throughout this myomatous tissue are irregular areas of uterine 
mucosa, near the surface directly continuous with that lining the 
uterine cavity, but in the depth appearing as bands of mucous mern- 
brane surrounded by myomatous tissue. The glands in the depth 
frequently show some dilatation giving rise to the cyst-like spaces 
noted macroscopically. Nearly all of the glands are surrounded 
by the characteristic stroma of the mucosa. 

Covering the outer surface of the uterus is a zone of normal 
muscle, averaging 4 or 5 mm. in thickness. This is totally devoid 
of gland elements. 

The case is a most instructive one. We have a small uter- 
ine cavity surrounded on all sides by normal 
mucous membrane. This mucous membrane 
has an outer covering varying from 3 to 5 
cm. in thickness and consisting of diffuse 

Fig. 16. — Extension of uterine glands into the diffuse myomatous tissue of an adeno- 

MYOMA. (50 diameters.) 

Gyn.-Path. No. 2066. The section is from the body of the uterus in Fig. 13. 
a represents the limits of the mucosa; the surface epithehum is intact and normal. The mucosa 
is of the usual thickness and its glands are unaltered. The stroma between the glands is slightly 
rarefied in the superficial portions owing to a slight edema. In the vicinity of b are a number 
of glands lying in the muscle. At c we have fortunately been able to trace a gland by continuity 
from the mucosa for a considerable distance into the diffuse myoma. It divides into two branches 
(c'), which extend further into the growth. Accompanying the gland c are d and e. These have 
been much convoluted, as only occasionally we catch a glimpse of them, at d' and d" and e' and 
e". In following the glands c, d, and e from above downward, one gathers the impression that 
all the cross-sections seen in the lower third of the field are cross-sections of the terminal portions 
of the three glands. Accompanying the glands and separating them frorh the diffuse myomatous 
growth is the stroma of the mucosa. 



60 ADENOMYOMA OF THE UTERUS 

myomatous tissue which has innumerable 
chinks everywhere traversing it and allowing 
the normal mucous membrane to flow in 
and fill them up. The whole of this adeno- 
myomatous mass is enveloped in a thin cap- 
sule of normal uterine muscle. 

The Fallopian tubes accompanying the uterus are normal. 

Diagnosis . — Adenomyoma, occupying both the anterior 
and posterior uterine walls; in other words, forming a complete 
zone around the uterine cavity. Normal Fallopian tubes. 

Gyn. No. 9457. Path. No. 5668. 

jMultinodular myomatous uterus with 
marked adhesions: Diffuse adenomyoma in 
the fundus with a definite tendency for the 
mucosa to penetrate into the muscle. Dis- 
crete adenomyoma near the uterine horn. 
Adenom3^omatous tissue in the left uterine 
wall at the junction of the broad ligament. 
Large cyst of the right ovary, probably un- 
dergoing carcinomatous transformation. 

M. H., married, white, aged forty-five. Admitted March 10, 
1902; discharged April 8, 1902. Comes for removal of a tumor 
and cure of inguinal and umbilical hernise. For the past year the 
patient has menstruated every four to six weeks, and recently 
there has been a yellowish, non-irritating, vaginal discharge. She 
has been married eight years, has had no children and no miscar- 
riages. Three or four years ago she noticed a lump in the right lower 
abdomen. This has greatly increased in size until the present time. 
The growth has apparently been more rapid during the last six 
weeks. 

Operation . — Pan-hystero-salpingo-oophorectomy ; radical 
cure of hernise, the abdominal incision extending from the ensi- 
form to the symphysis. The bowel was adherent to the cyst and 
also at the hernial ring. The ureters were misplaced and the rectum 



DIFFUSE ADENOMYOMA OF THE UTERUS 61 

was adherent to the uterus. The cyst was everywhere adherent 
to the lateral abdominal wall. The ureters ran from the pelvic brim 
almost straight across to the uterine cornua, being about 5 to 6 cm. 
long, from the pelvic brim to the point of attachment of the uterus. 

Each ureter was dissected free for a distance of 8 to 10 cm.; 
then the adherent peritoneum was gradually worked away, exposing 
the uterine vessels which were tied. The right ureter was accidentally 
caught in a large pair of artery forceps but freed two or three minutes 
later. The patient's convalescence was slow, owing to her great 
weakness. She was discharged well on the twenty-eighth day. 
Her highest temperature after operation was 102° F. 

Path. No. 5668 . — The specimen consists of the uterus, 
left tube and ovary, and a very large ovarian cyst. The uterus is 
11 cm. long, 9 cm. broad, and is covered with dense adhesions, 
some of which contain adipose tissue. Its removal has evidently 
been associated with great difficulty. The enlargement of the uterus 
is due chiefly to the presence of a myoma, 9 by 8 cm., in the anterior 
wall. There is also a nodule, 3 cm. in diameter, situated just an- 
terior to the left tube. The posterior wall of the 
uterus is considerably thickened owing to 
the presence of a diffuse myomatous condi- 
tion. 

The left tube and ovary are enveloped in adhesions; otherwise 
they appear normal. The right tube is 8 cm. long and attached to 
a cyst. The cyst is approximately 20 cm. in diameter; it is hard 
and smooth, but is covered with many adhesions, and has projecting 
from its surface numerous hard nodules. These vary from 3 to 4 
cm. in diameter. On section they are whitish-yellow in color, homo- 
geneous in consistency, and divided up into alveoli by a septum of 
connective tissue. The cyst walls vary from 3 to 4 cm. in thickness. 
The inner surface is in places smooth, but at numerous points the 
thickening is due to a shaggy growth which in places is covered by 
recent clots. At one point is a nodule, 4 cm. in length and 3 cm. 
in breadth, projecting into the cavity. This nodule is porous and 
closely resembles a carcinomatous growth. 



62 ADENOMYOMA OF THE UTERUS 

Histological Examination . — Sections from the 
uterus show that the epithelium is intact. The mucosa is 
normal but shows a decided tendency in 
places to penetrate the underlying muscle 
en masse. Situated just posterior to the left uterine comu 
is a circumscribed adenomyomatous nodule, fully 2 cm. in diameter. 
The gland elements in this case are clearly visible to the naked eye. 
The islands of mucosa vary from a pin-point to 2 or 3 mm. in length. 
They differ in no way from normal mucosa. Sometimes isolated 
glands are found. These are invariably separated from the muscle 
by the normal stroma of the endometrium. A few of the glands are 
dilated and are filled with brownish pigment. The nodule is very 
sharply circumscribed from the surrounding tissue. In the wall of 
the uterus where it joined the left broad ligament one of the glands 
is fully 3 mm. in diameter. It is filled with pigment and fresh 
blood-cells. 

The ovarian cyst has an inner lining of one layer of cylindrical 
epithelium. At many points there has been hemorrhage with sub- 
sequent partial organization of the clots. The inner epithelial 
lining in many places has proliferated, forming new glands, and 
these at some points are so crowded together that the masses of 
epithelial cells resemble sarcomatous tissue. The individual cells 
are fairly uniform. Some of them, however, are considerably en- 
larged and stain intensely. Although the growth may be now con- 
sidered as an adenocarcinoma, it has originally been a simple cyst. 

Diagnosis . — Multinodular myomatous uterus with marked 
adhesions. Diffuse adenomyoma of the fundus, discrete adeno- 
myoma. Adenomyomatous tissue in the left uterine wall at the 
junction of the broad ligament. Cyst of the right ovary probably 
undergoing carcinomatous transformation. 

H. A. K. Sanitarium No. 469. Path. No. 1758. 
Diffuse adenomyoma of both the anterior 
and posterior uterine walls with the glands 
coming from the mucosa. 



DIFFUSE ADENOMYOMA OF THE UTERUS 63 

W. J. R., white, married, aged fifty-five. Admitted May 21, 
1897; discharged July 2, 1897. The patient has had six children. 
The menses began at nineteen and occurred every three weeks. 
They were very free. Eight years ago she had a prolapsus, and 
during the last year it has been exceedingly difficult to keep the 
uterus within the vagina. 

Operation . — Ilystero-salpingo-oophorectomy. 

The uterus was removed entirely. The patient made a very 
satisfactory recovery. 

Path. No. 1758 . — The specimen consists of the uterus 
and the right tube and ovary. The uterus measures 9.5 by 7.5 
by 5 cm. It is free from adhesions. At the left uterine cornu is a 
myomatous nodule 2.5 cm. in diameter. The cervical canal is 
2 cm. in length. The uterine cavity is 5.5 cm. long. The mucosa 
lining the cavity is much thickened and there is a distinct projection 
from the posterior wall. The anterior uterine wall 
presents a diffuse myomatous a p p e a r a n c e a nd 
here and there one can see fine porous areas 
varying from 1 to 3 or more millimetres in 
diameter. At some points, especially at the fundus, the 
mucosa can be seen with the naked eye extend- 
ing for 7 mm. into the myoma. The same picture 
is found in the upper part of the cavity. The projection from the 
cavity into the posterior wall is due to a diffuse myomatous thick- 
ening. The posterior wall reaches 3.5 cm. in thickness. Here also 
are a few porous areas, evidently islands of uterine mucosa. 

On histological examination the vaginal por- 
tion of the cervix is found to be normal. Sections from the anterior 
and posterior walls show normal uterine mucosa. At numerous 
points this mucosa is found flowing into the 
underlying myoma. This is clearly demon- 
strable throughout the entire uterine cavity. 
The islands of mucous membrane everywhere are perfectly normal 
save for dilatation of the glands. The islands are most abundant 
near the mucosa and are totally absent in the vicinity of the peri- 



64 ADENOMYOMA OF THE UTERUS 

toneum. We have here another example of a diffuse adenomyoma 
occupying both the anterior and posterior walls, with the gland 
elements everywhere derived from the uterine mucosa. 

Gyn. No. 2744. Path. No. 274. 

Diffuse myomatous thickening of the 
uterine walls, partly of the adenomyomatous 
type (Figs. 17 and 18). Well-defined subperito- 
neal and interstitial myomata; subacute 
endometritis; slight pelvic peritonitis. 
Hysterectomy. Recovery. 

S. J., married, aged thirty-two, colored. Admitted April 28; 
discharged June 23, 1894. 

Menses regular up to two years ago, since when they have in- 
creased in frequency, with pain at the periods. 

She has had six children, four still-born, two dying at seven 
months. The last child was born six months ago. The bowels have 
been constipated ; micturition has been frequent. For the past year 
she has had pain in the left side and back, growing gradually worse. 

Examination . — Five distinct myomata could be felt on 
the surface of the uterus, varying in size from 1 cm. to 6 cm. 

Lips and mucous membranes pale. Haemoglobin 39 per cent. 

First Operation . — April 2, 1894. Dilatation and 
curetting. Uterine cavity tortuous. A considerable amount of 
endometrial tissue was removed. The patient was discharged on 
April 13, 1894. 

Second Operation . — April 28, 1894. Hystero-myo- 
mectomy. Double salpingectomy. Incision 10 cm. The uterus 
was myomatous and contained irregular and nodular masses, which 
had developed mostly from the posterior wall and fundus. There 
was a double salpingitis with hydrosalpinx and double peri-oophoritis. 
There was some suppuration of the abdominal incision. 

The temperature varied between 99° and 102° F. for nine days 
after the operation, reaching 102.2° F. on the ninth day. Pulse 
80 to 114 (maximum on the third day). The temperature for a 



DIFFUSE ADENOMYOMA OF THE UTERUS 



65 



month occasionally rose to 100° F. The pulse was below 88 after 
the eleventh day. 

Result: Recovery. 

Gyn.-Path. No. 274 . — The specimen consists of the 
uterus and appendages intact. The uterus has been converted into 
an irregular mass 7 cm. long, 8 cm. from side to side, and 11 cm. in 
its antero-posterior diameter. It is pinkish in color, smooth and 



a 




_„_a 



Fig. 17. — Interstitial and subperitoneal uterine myomata. Interstitial adenomyoma. 

(Natural size.) 

Gyn.-Path. No. 274. This is an antero-posterior section of the uterus. The 
figures a, a, a, a, indicate myomata, one in the anterior wall and three in the posterior. The 
anterior wall, not implicated by the myomata, is considerably thickened. The organ has been 
amputated through the cervix. The uterine cavity is of the normal length. The mucosa of the 
anterior wall is much thickened, but its surface is relatively smooth. Some of the glands are 
dilated, forming small cysts. The mucosa of the posterior wall is little altered, but it also shows 
some glandular dilatation. The area represented by h has been magnified and is shown in 
Fig. 18. It contains a small diffuse adenomyoma. 



glistening. Scattered here and there over the surface are bright 
red vascular adhesions. Springing from the posterior surface is a 
firm nodule, 5 cm. in diameter; from the left side is a similar one, 
2.5 cm. in diameter. The under cut surface of the uterus is 7 by 5 
cm. (Fig. 17). The uterine walls average 3.5 cm. in thickness, are 
pinkish in color, and contain several nodules, the largest of which is 
2.5 cm. in diameter. The nodule situated in the posterior wall 
and also those scattered throughout the uterus are pearly white in 



66 



ADENOMYOMA OF THE UTERUS 



appearance, are composed of concentrically arranged fibres, and 
are firm and non-yielding. The portion of the uterine cavity present 
measures 2.5 cm. in length. The mucosa is apparently 1 mm. in 
thickness, is pale and glistening, and in places presents ecchymoses. 




'/?■ 



e , 



/ 




JC^eeher J.-, 




Fig. 18. — Small adexomyoma ix the fundus of the uterus. (3 diameters.) 

Gyn.-Path. No. 274. The section represents the area h seen in Fig. 17. a is the 
upper part of the uterine cavity; h is the thickened mucosa of the anterior wall. The glands on 
the whole are normal, except that there is dilatation of some few of them. The line of demar- 
cation between mucosa and muscle is irregular and not well defined. The glands show a tendency 
to invade the muscle, c represents the mucosa in the posterior wall. This is thin, and there is 
some gland dilatation, but the mucosa is sharply outlined from the muscle. At d there is a regular 
colony of glands deep down in the muscle. They bear a marked resemblance to the normal 
uterine glands. From the text it will be seen that some of them are surrounded by the char- 
acteristic stroma of the mucosa. Others lie in direct contact with the muscle. The surrounding 
tissue and the uterine walls generally are made up of a diffuse myomatous tissue. At e and e' are 
discrete myomata. 



Near the fundus is a polyp 1.5 cm. in diameter, 5 mm. in thickness. 
(The uterus was curetted one month ago.) 

Histological Examination . — A description of the 
uterine mucosa is unsatisfactor\^, as the uterus has so recently 
been curetted. Sections from portions that have been unmolested 
show that the surface epithelium is intact. The glands are few in 



DIFFUSE ADENOMYOMA OF THE UTERUS 67 

number and some of them are considerably dilated. The stroma 
of the mucosa shows a good deal of small round-cell infiltration. 
At several points near the fundus the glands 
are seen extending fully 3.5 mm. into the 
muscle. Here they are somewhat dilated, but are still sur- 
rounded by the stroma of the mucosa. At the fundus the muscle 
contains an irregular area 7 mm. in diameter and everywhere 
traversed by cyst-like spaces (Fig. 18). These represent dilated 
uterine glands which are surrounded by a small amount of stroma. 
Scattered throughout such an area are also numerous glands of 
normal size. These, however, lie directly between muscle bundles. 
The epithelium of some of the glands stains ver}^ palely. The 
thickening in the uterine walls is to a great extent due to a diffuse 
myomatous transformation of the muscle. The nodules scattered 
throughout the uterus present the typical myomatous appearance 
and in many places these have undergone h3^aline degeneration. 

In this case we have a diffuse myomatous thickening of the uterine 
walls with localized infiltration by normal uterine mucosa; also 
the presence of several well-defined myomata. The right tube and 
ovary are covered with numerous adhesions. The left tube and 
ovary are normal. 

Diagnosis .—Subacute endometritis, diffuse myomatous 
thickening of the uterine walls, partly of the adenomj^omatous 
type; well-defined subperitoneal and interstitial myomata; slight 
pelvic peritonitis. 

Union Protestant Infirmary (Dr. Russell). Path. No. 9858. 

Commencing adenomyoma in the body of 
the uterus; early adenomyoma of the right 
uterine horn; general pelvic adhesions. 

The specimen consists of a small uterus with appendages. The 
uterus has been amputated through the cervix and is 5 cm. in length, 
6 cm. in breadth, and 4 cm. in its antero-posterior diameter. The 
appendages on both sides are thickened and adherent. Projecting 
from the fundus is a myoma, 3 cm. in diameter, and there are several 



68 ADENOMYOMA OF THE UTERUS 

adhesions. The uterine walls are slightly thickened. The mucosa 
looks normal. The right tube is cystic and reaches 1 cm. in diameter 
near its outer end, where it is adherent to the slightly enlarged and 
cystic right ovary. The left tube and ovary are enveloped in adhe- 
sions. 

Histological Examination . — The surface epithe- 
lium is intact. The stroma of the mucosa is normal. At some 
points the mucosa is seen extending into the 
depth for a short distance and bands of myo- 
matous muscle are coming in and gradually 
separating off this mucosa that is penetrat- 
ing the depth. The underl3dng muscle is more wavy than 
usual and looks somewhat myomatous. It is evidently a very 
early adenomyoma. Sections from the right uterine horn show that 
the tube at this point is normal. The muscle just beneath shows a 
distinct myomatous tendency. Near the peritoneal surface and 
also near the tube are gland-like spaces, some of them occurring 
singly, others in small colonies. These gland-like spaces lie in 
direct contact with the muscle and have a very high cylindrical 
epithelium. Where they occur in groups they are also in direct 
contact with the muscle and are lined with high cylindrical epithe- 
lium, in each case surrounded by a definite zone of myomatous 
muscle. Just beneath the peritoneum is a gland-like space lined 
with cuboidal epithelium. Elsewhere throughout the muscle in the 
vicinity we find recent mj^omata which are being gradually differ- 
entiated from the normal muscle. 

The right tube shows a hydrosalpinx, but, apart from adhesions, 
nothing abnormal. 

Diagnosis . — General pelvic adhesions and commencing 
adenom3^oma of the right uterine horn. 

Gyn. No. 6083. Path. No. 2356. 
Diffuse adenomyoma involving the ante- 
rior wall, left side, and a portion of the pos- 
terior uterine wall, and containing miniature 



DIFFUSE ADENOMYOMA OF THE UTERUS 



69 



uterine cavities just beneath the peritoneal 
surface (Figs. 19, 20, 21, and 22). Hysterectomy. 
R 'e c o V e r y . 

M. T., married, aged twenty-three, black. Admitted May 26, 
1898 ; discharged June 6, 
1898. She complained 
of an enlargement in the 
lower abdomen. This 
was associated with pain. 
She had had one child, 
no miscarriages. Men- 
struation had been regu- 
lar, every four weeks, 
lasting from four to five 
days; flow scanty. She 
had had no pain until 
five years previous^. 
Since then the menses 
had been irregular and 
the flow excessive, last- 
ing at times for two 
months and necessitat- 
ing her remaining in 
bed. 

At present the pain 
in the lower abdomen 
is sharp and intense. 
During the last month 
there has been con- 
stant bleeding, except 
for intervals of two or 
three days. There is no increase in frequency of micturition. 

The lower half of the abdomen is distended and there is marked 
tenderness on the left side, as well as in the inguinal and hypo- 
gastric regions. The outlet is well lifted up, the cervix is small. 




Fig. 19. — Diffuse adenomyoma of the uterus. (Nat- 
ural size.) 

Gyn.-Path. No. 2356. The section is an an- 
tero-posterior one through the left side of the uterus. At 
this point nearly the entire uterine wall is composed of a 
diffuse myomatous growth. At points a, a, however, a 
small amount of normal uterine muscle remains. In other 
places the growth reaches the peritoneum. Scattered 
throughout the myoma are round, oval, irregular or slit- 
like cavities with smooth inner linings. They are most 
abundant and reach their greatest diameters just beneath 
the peritoneum. Here they have a lining resembling mu- 
cosa which in places reaches 1 mm. or more in thickness. 
The two cyst spaces, seen at h, are in reality merely two 
cross-sections of one convoluted cavity. (See Fig. 21.) 
At c one of the cyst-like spaces can be traced as a slit for 
a considerable distance into the growth. On histological 
examination the large cyst-like spaces proved to be mini- 
ature uterine cavities. (See Figs. 21 and 22.) 



70 ADENOMYOMA OF THE UTERUS 

The OS admits the index-finger and the uterus is represented by a 
mass approximately 10 cm. in diameter. The lateral structures 
cannot be outlined. 

Operation . — Hystero-myomectomy. The patient made a 
perfect recover}^ 

Path. No. 2356 . — The left side of the fundus shows some 
faintly raised bosses, which can be traced a short distance over the 
left posterior aspect. They are slightly yielding on pressure. The 
uterine cavity is 4.5 cm. in length and 3.5 cm. in breadth at the 



'..'^ 









■n'O '^j 







d e f c 

Fig. 20. — Diffuse adexomyoma of the uterine wall. (4 diameters.) 

Gyn -Path. No. 2356. The section is from the body of the uterus. A glance at a 
shows that the mucosa is very thin and that some of the glands are dilated. At 6 is a small 
polypoid outgrowth consisting of normal mucosa. The uterine wall is transformed into the 
diffuse myomatous growth. At c the normal mucosa is seen extending for quite a distance into 
the diffuse myoma, and at points d, d, we have islands of the mucosa in the depth. At e there is 
considerable gland dilatation. Distributed here and there are isolated glands accompanied by 
their stroma, and at / is an island of stroma devoid of gland elements. The glandular elements of 
this diffuse adenomyoma have undoubtedly arisen from uterine glands. 

fundus. The mucosa has a roughened surface, is about 2 mm. in 
thickness, and has springing from it several small polypi, varying 
from 2 to 8 mm. in length. The posterior uterine wall 
varies from 2.5 to 3 cm. in thickness. It is 
easil)^ divisible into two portions; an inner, 
about 2.5 cm. in thickness, very dense in 
character, consisting of strands running in 
all directions and closely resembling myo- 
matous tissue. This can be traced as far as 
the mucosa, but is easily differentiated from 



DIFFUSE ADENOMYOMA OF THE UTERUS 71 

it. The outer portion of the posterior wall 
consists of normal uterine muscle. The anterior 
uterine wall is about 4 cm. in thickness and differs materially from 
the posterior. It consists almost entirely of coarse bands of tissue 
running in all directions and forming definite whorls. In the fresh 
state, small cyst-like spaces were seen scattered throughout the 
myomatous tissue, but the differentiation was not marked. After 
hardening in Mliller's fluid, however, these cyst-like spaces, which 
vary from .5 to 5 mm. in diameter, are found to be situated in a 
fairly homogeneous tissue devoid of fibres and totally different from 
the surrounding myomatous tissue. Furthermore, in this homo- 
geneous tissue are many small openings, somewhat punctiform in 
character. These areas resemble uterine mucosa, and on examining 
the mucosa of the anterior wall we can at some points see the mucous 
membrane penetrating the muscle for at least 4 mm. These islands 
of homogeneous tissue, which resemble mucosa, vary greatly in 
shape. Some are comparatively round, others oblong, but the 
majority are triangular (Fig. 19). They are abundantly scattered 
throughout the myomatous tissue. The growth occupying the 
thickened anterior uterine wall, and consisting, as we have seen, of 
myomatous tissue and islands of mucosa, also involves the left side 
and to some extent the left posterior aspect of the uterus. It has 
an outer covering of uterine muscle, averaging 3 mm. in thickness. 
But at the points at which we noted the bosses on the left and pos- 
terior aspects of the uterus it has practically reached the peritoneal 
surface. On making an antero-posterior section through the uterus, 
near the insertion of the left tube, it is seen that the diffuse myoma 
contains several irregular cyst-like spaces a short distance beneath 
the peritoneal covering. The largest of these is 6 mm. in diameter. 
All have smooth inner linings which resemble mucous membrane. 
This inner covering is fully .5 mm. in thickness. 

Histological Examination . — Sections from the 
posterior wall of the uterus in the mid-line show that the surface of 
the mucosa has in part disappeared. The underlying glands show 
no change, but the muscle directly beneath the mucosa reveals con- 



72 



ADENOMYOMA OF THE UTERUS 



siderable proliferation of the connective tissue around the smaller 
blood-vessels. The muscle bundles are denser than usual and show 
a greater tendency to wind in and out. No glands are demonstrable 



f 



.■--/•;,-• rwr-rf-i-. .-■^K-.t-^- 







"H^.Bscker 



Fig. 21. — Cyst-like spaces just beneath the peritoneum in a diffuse adenomyoma of the 

UTERUS. (12 diameters.) 

Gyn.-Path. No. 2356. The section represents the area b in Fig. 19. a is the thin 
outer covering of normal muscle; a' the peritoneum, b is one of the cyst-like spaces; it is lined 
with a definite mucosa. This mucosa has a surface epithelium and beneath it a mucous mem- 
brane containing many glands. The majority are small and round. Some of them are, however, 
dilated and convoluted. For the finer structures see Fig. 22, which is the area c much enlarged. 
The mucosa cannot be distinguished from the normal uterine mucosa and the entire cyst resembles 
a small uterine cavity. At d is an area of mucosa identical with that normally found lining the 
uterine cavity, e, e' , e" , e'" are evidently cross-sections of one cavity which is much convoluted. 
The mucosa in them resembles that lining the cavity b. The cyst space b and those represented 
by e, e' , e" , e'" are also evidently part of the same cavity as seen by the connecting link of the 
mucosa /. 

in the muscle. The mucosa of the anterior wall has also lost its 
surface epithelium except at protected points. This loss is un- 
doubtedly due to the faulty preparation of the specimen. The glands 



DIFFUSE ADENOMYOMA OF THE UTERUS 73 

in the mucosa, on the whole, are normal. A few of them, however, 
are dilated. At one point the mucosa is seen ex- 
tending 4 mm. into the underlying muscle 
(Fig. 20). Here the glands and stroma seem to penetrate in the 
form of a wedge, and the muscle is to some extent arranged parallel 
with this entering wedge. The thickened anterior uterine wall is 
composed of myomatous tissue presenting the usual appearance and 
traceable up to the mucous membrane. Scattered freely 
throughout the mj^omatous tissue are islands 
of glands. These glands are usually circular or oblong in form 
and lined with one layer of fairly high cylindrical ciliated epithelium. 
They are invariably surrounded by stroma similar to that of the 
uterine mucosa. In fact, they appear to be nothing more than 
large and small islands of uterine mucosa scattered throughout the 
myomatous tissue. Some of the glands are dilated, and where such 
dilatation has occurred, the epithelium is usually paler and somewhat 
flattened. Such glands often contain desquamated epithelial cells 
and granular material — evidently coagulated serum. A few of the 
desquamated cells contain pigment droplets, the result of an old 
hemorrhage. Occasionally we find an isolated gland in the muscle 
or a small amount of stroma lying alone between muscle bundles. 
The muscle covering the outer surface of this diffuse myoma is 
normal. 

The large cyst-like spaces seen in the mj^- 
oma in the vicinity of the left horn are 
throughout lined with mucous membrane 
identical with that of the uterine mucosa 
(Figs. 21 and 22). The inner surface of each has a covering of one 
layer of epithelium, cylindrical in character, except where the space 
is very much dilated. Here the epithelium is pale-staining and 
cuboidal or almost flat. Occasionally, there is a little tuft of epithe- 
lium projecting into the cavity, but the individual cells of such 
tufts are in no way suspicious. Here and there the epithelium is 
raised by an old blood-clot which is partially organized. Beneath 
the epithelium are typical uterine glands, normal in appearance and 



74 



ADENOMYOMA OF THE UTERUS 



separated by the characteristic stroma of the mucosa. If we were to 
take a section through a portion of one of these cyst walls, it would 
be impossible to differentiate it from the mucosa lining a normal 
uterine cavity (Fig. 22). 

We have in this uterus a diffuse adenomy- 
oma consisting of coarse myomatous tissue, 
everywhere invaded by islands of uterine 



-c 




d 

Fig. 22. — The mucosa lining one of the cyst-like spaces situated just beneath the 

PERITONEUM IN A DIFFUSE ADENOMYOMA OF THE UTERUS. (85 diameters.) 

Gyn.-Path. No. 2356. The section is the area c in Fig. 21 much enlarged, a 
represents the mucosa; 6, the myomatous muscle. The surface of the mucosa is comparatively 
regular and is covered by a single layer of cylindrical epithelium. At two points glands are 
seen opening on the surface. The glands of the mucosa are round or oval on cross-section, and are 
lined with cylindrical epithelium. Surrounding the glands and separating them from the muscle 
is a definite stroma. In this the endothelial cells of the blood capillaries are moderately swollen, 
c is a gland showing some branching; (/ and d are the bases of glands so cut as to resemble solid 
nests. This mucous membrane resembles uterine mucosa in every particular, and given such a sec- 
tion, not knowing its source of origin, we should unhesitatingly say that it was normal mucosa 
from the uterine cavity. 

glands, differing in no way, except for their 
dilatation, from normal uterine mucosa. 
The growth occupies the entire anterior uter- 
ine wall, the left side, and also the left 
portion of the posterior wall. This diffuse 
adenomyoma has, as was noted, an outer 
covering of uterine muscle, but on the left 



DIFFUSE ADENOMYOMA OF THE UTERUS 75 

side has reached the surface and is recog- 
nized as small bosses. The growth is certainly benign. 

Gyn. No. 3136. Path. No. 497. 

Diffuse a d e n o m y o m a of the anterior uter- 
ine wall (Figs. 23, 24, 25, 26). Glandular ut^fe'rine 
polyp; small interstitial and subperitoneal 
myomata. Hysterectomy. Recovery. 

L. W., aged forty-six, white, single. Admitted October 24, 1894. 
Complaint: Pain in lower part of the abdomen, painful and profuse 
menstruation. Menstruation commenced when she was eleven 
years of age and was always regular. For the past ten years she 
has had severe pains in the right ovarian region at the menstrual 
period. These pains radiated down both limbs, were accompanied 
by backache, and for the last two years have been so severe that she 
has been confined to bed for three or four days at each period. At 
present the flow lasts from ten days to two weeks and there is a 
considerable amount of clotted blood. Her last period ceased one 
week before admission. Her parents are both living and healthy. 
One brother died of tuberculosis. With the exception of an attack 
of diphtheria several years ago and influenza three years ago, she has 
always been well. 

Present Condition . — TJie patient is a rather ansemic 
woman and does not appear to be very strong. Her tongue is pale 
and flabby; the appetite is fair, the bowels are regular. She is 
unable to walk much and cannot lift heavy weights. Vaginal ex- 
amination: The outlet is very much relaxed, and presenting at the 
orifice is a hard, irregular mass which proves to be the cervix. The 
external os is patulous, admitting the index-finger, and projecting 
from the os is what appears to be a myomatous nodule about 2 cm. 
in diameter. The cone-shaped cervix is continuous with the en- 
larged uterus, which is apparently freely movable. 

Clinical Diagnosis . — Myoma. 

Operation Oct. 31, 1894 . — On opening the abdo- 
men it was found impossible to raise the uterus out of the pelvis, 



76 ADENOMYOMA OF THE UTERUS 

and the operator was compelled to work in the narrow space between 
the uterus and the pelvic walls. The ovarian and uterine vessels on 
both sides were controlled and the uterus was amputated. The lips 
of the stump were then brought together, and, lastly, the peritoneum 
from the posterior wall was sutured to that of the anterior, thereby 
completely covering over the stump. The patient made an un- 
interrupted recovery, and was discharged December 1, 1894. 

Gyn.-Path. No. 497 . — The specimen consists of the 
enlarged uterus with its tubes and ovaries intact. The uterus 
is 13 cm. long, 12 cm. broad, and 10 cm. in its antero-posterior 
diameter. It is approximately globular and in its contour resembles 
a normal but enlarged uterus. Anteriorly it is smooth and gUsten- 
ing ; posteriorly over its lower two-thirds it is denuded of peritoneum. 
Situated in the posterior wall in the vicinity of the left uterine cornu 
are four sessile nodules, which are approximately circular. The 
largest of these is 2 cm. in diameter. On section they are whitish 
in color and are composed of fibres concentrically arranged. They 
present the usual myomatous picture. The under cut surface of 
the uterus measures 12 by 11 cm. In the centre of this is the cer- 
vical opening, which is 1 cm. in diameter. Projecting from the 
right side of this opening is a nodule 2.5 cm. in diameter; this is 
apparently covered with mucous membrane which is somewhat 
hemorrhagic. 

The anterior uterine wall is 7 cm. in thick- 
ness (Fig. 23) ; it can be divided into two dis- 
tinct portions; the outer, 1 cm. thick, re- 
sembles normal uterine muscle; the remain- 
der of the wall presents a coarsely striated 
appearance, the striae running in all direc- 
tions. Scattered throughout this thickened 
and striated portion of the uterine wall are 
round, oval, or elongate, b r o wn i s h -y e 1 1 o w , 
homogeneous areas, some of which merge 
directly into the uterine mucosa. In one 
or two places small cysts, varying from 1 to 



DIFFUSE ADENOMYOMA OF THE UTERUS 



77 



4 mm., can be seen scattered throughout this 
thickened portion of the uterine wall. The 
striated appearance can be traced directly 




Fig. 23. — Diffuse adenomyoma of the anterior uterine wall, (ff natural size.) 

Gyn. No. 497. The uterus has been cut open and is seen from the front. The drawing 
is from the specimen hardened in Miiller's fluid. A small portion of the cervix is present. Pro- 
jecting through the cervical opening is a globular nodule (a) whose pedicle springs from the uterine 
cavity just within the internal os. On histological examination this was found to be a myoma 
everywhere penetrated by glands. The anterior uterine wall is much thicker than usual. It is 
divisible into two portions, an inner coarsely striated and an outer but narrower zone which is the 
normal uterine muscle. This outer zone presents a parallel arrangement of its muscle bundles. 
On examining the fundus carefully the coarse striation is seen to be confined to the anterior wall. 
The uterine mucosa, apart from slight undulation of the surface, is smooth. The small folds 
described as occurring near the internal os are obscured by the polyp. One of the most striking 
features is that there is practically no encroachment of the growth on the uterine cavity, the 
anterior wall showing little, if any, convexity. This is in marked contrast to what takes place 
in cases of submucous myomata. For the histological picture see Figs. 24, 25, and 26. 

up to the uterine mucosa, and in some places 
into it. After hardening the specimen in Miiller's fluid the 
contrast between the normal uterine muscle and the thickened 



78 



ADENOMYOMA OF THE UTERUS 




■"H'.'"! 



striated portion is very sharp, the 
uterine muscle being much darker 
in color than the striated portion. 
The posterior wall of the uterus varies 
from 2.5 to 3.5 cm. in thickness. It 
is rather dense, but does not present 
any coarse stria tions. Situated in 
the posterior wall are two interstitial 
nodules 1 and 1.5 cm. in diameter; 
they are pearly white in color and 
are composed of concentrically ar- 
ranged fibres. 



Fig. 24. — Diffuse adenomyoma of the .vnterior 
UTERINE WALL. (3 diameters.) 

Fig. 24 is a cross-section from the thickened an- 
terior uterine wall in Fig. 23. a indicates the uterine 
mucosa, b the adenomyomatous zone and c the nor- 
mal outer covering of uterine muscle. The surfaoe 
of the mucosa presents a wa%'y outline. The surface 
epithelium is intact and the glands are for the most 
part normal in size. A few of them are dilated, one 
reaching a considerable size. On passing to the mus- 
cle large numbers of longitudinal glands are seen 
penetrating downward into the growth between the 
muscle bundles. These are surrounded by a tissue 
darker than the muscle — the typical stroma of the 
mucosa. The greater part of the specimen is com- 
posed of bundles of muscle fibres. Some of the bun- 
dles present a circular arrangement, others are ob- 
long and some wind in and out in all directions. 
These large bundles are again subdivided into 
smaller ones. Scattered everywhere through the 
thickened zone are dark areas. Some of these are 
triangular; some are semicircular, while others are 
irregular in shape. On examining these areas closely, 
the majority are found to contain longitudinal or 
cross-sections of glands. Some of these glands are 
dilated and irregular in contour. A longitudinal sec- 
tion of a gland with a dilatation on one side is seen 
near the junction of the myomatous zone with the 
uterine muscle. The large clear spaces scattered 
throughout the myomatous zone are dilated glands. Here and there a dark patch is seen in 
which no glands are present. Islands of stroma devoid of glands also occur. The glandular 
elements diminish in number in the outer portions of the growth and at the point where the 
uterine muscle commences they are absent. The outer zone consisting of uterine muscle presents 
the appearance of normal muscle. 



a :-^?: 




'•^ 



I 




•^ 



-- < 



DIFFUSE ADENOMYOMA OF THE UTERUS 79 

The uterine cavity is 7.5 cm. in length, and at the upper part 8 cm. 
in breadth. The mucous membrane of the an- 
terior uterine wall varies from 7 to 8 mm. 'in 
thickness, is yellowish-white in color, smooth and glistening. 
In many places, however, it presents ecchymoses in the superficial 
portions. In the vicinity of the internal os and extending upward 
for about 2.5 cm. are three or four longitudinal folds of the mucosa. 
The depressions between these are about 4 or 5 mm. in depth. The 
mucosa covering the posterior wall varies from 3 to 4 mm. in thick- 
ness. 

Right side: The tube is 11 cm. long, and averages 7 mm. in 
diameter. Its fimbriated extremity is patent; the parovarium is 
intact. The ovary measures 8 by 2.5 by 1.5 cm., is pale white in 
color, smooth and glistening. It contains two corpora lutea, the 
larger of which is 2.5 cm. in diameter. 

Left side: The tube is 9 cm. long and 6 mm. in diameter. Its 
extremity is patent ; the parovarium is intact. The ovary measures 
4 by 4 by 1 cm., is yellowish-white in color and somewhat lobulated. 
It contains a cyst 2.5 cm. in diameter. The walls of this are 2 mm. 
in thickness and the inner surface is dirty brown in color. 

Histological Examination . — The nodule project- 
ing into the uterine canal is composed of non-striped muscle fibres. 
Its outer surface is in places covered with cylindrical epithelium, but 
in most places apparently with several layers of spindle-shaped 
connective-tissue-like cells. Scattered everywhere throughout this 
muscle are gland-like spaces varying from a pin-point to 3 mm. in 
diameter. These are lined with one layer of epithelium, which in the 
smaller glands is of a high cylindrical variety. In the dilated glands, 
however, it is cuboidal, or has become almost flat. The protoplasm 
of the cells takes the hematoxylin stain. The nuclei are oval and 
vesicular, and in many places it is possible to make out the cilia. 
The glands are empty or contain a granular material that takes the 
hematoxylin stain. These glands resemble to some extent those of 
the cervix. 

The surface of the mucosa covering the anterior uterine wall 



80 



ADENOMYOMA OF THE UTERUS 



presents in places a wavy outline (Fig. 24). Its epithelium is of the 
high cylindrical variety and is everj^where intact. In a few places 
it is swollen and somewhat flattened. The glands are moderate in 
number, are small and round on cross-section, and have an intact 
"epithelium. A few of them are slightly dilated and contain desqua- 
mated epithelium. The glands may be traced for 
from 7 to 10 mm. before any muscular sub- 
stance is encountered; they then end abrupt- 
ly or continue into the muscle, where they 



















Fig. 25. — Cross-section of a gland taken from Fig. 24 at d. (150 diameters.) 

The gland is lined with one layer of cylindrical epithelium and is surrounded by cells having 
oval vesicular nuclei. Its appearance is identical with that of the normal uterine gland. Sur- 
rounding the stroma of the gland are non-striped muscle fibres, the majority of which are cut 
longitudinally. 

can in places be traced for at least 1 cm.; 
this down-growth is visible in many places. 
The stroma of the mucosa is composed of cells whose nuclei vary 
from the oval vesicular type, as seen near the surface, to deeply 
staining ones, as noticed in the depth of the mucosa. In some 
places the stroma cells have elongate oval nuclei; so that it is im- 
possible to distinguish them from muscle fibres. The superficial 
portions of the stroma show marked signs of hemorrhage, which is 
localized to certain areas. The stroma as a whole does not appear 
to be very vascular. 



DIFFUSE ADENOMYOMA OF THE UTERUS 



81 



The thickened and striated portion of the anterior uterine wall 
is composed of non-striped muscle fibres, which are for the most 
part cut longitudinally. The fibres run in all directions, are closely 
packed together, but only in a few places are concentrically arranged 
Scattered throughout this tissue are numerous cells having small, 
round, deeply staining nuclei which resemble those of lymphoid 




Fig. 26. — A branching gland from a glandular area in an adenomyoma. (85 diameters.) 

Gyn.-Path. No. 497. The section is taken from the diffuse growth in the anterior 
uterine wall in Fig. 23. a appears to be the main trunk of the gland. Upward we have three 
branches b, b' , b" , downward it can be traced to d and to the right as far as c. The gland with 
its various branches appears to be lined with numerous layers of cells. This is due to the thick- 
ness of the section. It is in reality lined with a single layer. There is nothing in the least sug- 
gestive of malignancy. At points e are sections of other glands. The gland / is cut on the bevel 
at /'. The stroma surrounding the glands is exceptionally dense owing to the unusual number of 
stroma cells. 

cells. Under the microscope it is impossible to tell where the coarsely 
thickened zone ends and the normal uterine muscle commences, 
the transition of the one into the other being so gradual. Traversing 
this thickened portion of the uterine wall are small clusters of glands, 
precisely similar to those of the uterine mucosa (Fig. 24). These 
glands are round or oval and are lined with one layer of cylindrical 

6 



82 ADENOMYOMA OF THE UTERUS 

ciliated epithelium. A few longitudinal sections of the glands are 
here and there visible. Some of the glands are dilated, one of them 
reaching 5 mm. in diameter. The epithelium of the dilated glands 
is in places somewhat flattened or has entirely disappeared. 

In one place two glands are seen opening into a dilated gland. 
Nearly all of the glands are surrounded by stroma similar to that of 
the uterine mucosa (Fig. 25). A small isolated gland is occasionally 
found lying directly between the muscle fibres, and a few of the 
cysts have no stroma surrounding them. The invasion by 
the glands can be traced to the point at which 
the coarsely striated tissue joins the uterine 
muscle. They are most abundant near the uterine mucosa and 
gradually diminish as one passes outward. They may be scattered 
anywhere throughout the myomatous growth, but appear for the 
most part to occupy the spaces between the muscle bundles. In only 
a few places can any concentric arrangement of muscle fibres be made 
out around the glands. The glands themselves show no evidence of 
degeneration. 

From the above it will be seen that there is a diffuse muscle 
thickening of the anterior uterine wall, and that there is a down- 
growth of normal uterine glands into the newly formed muscle. 
Along the lower margin of the growth is a typical myomatous nodule 
5 mm. in diameter. 

The mucosa covering the posterior wall is normal. 

The right tube and ovary are normal. 

The left tube is normal. The small cyst of the left ovar}^ has no 
epithelial lining, hence its exact origin cannot be ascertained. 

Gyn. No. 12,807. Path. No. 9699. 
Diffuse adenomyoma of the anterior wall 
w^i th commencing adenomyoma of the pos- 
terior wall. Gland elements derived from the 
uterine mucosa; a few discrete myomata; 
general pelvic adhesions; small Graafian fol- 
licle cyst on the right side. 



DIFFUSE ADENOMYOMA OF THE UTERUS 83 

A., colored, April 14, 1906. Operation: Hysterectomy; right 
salpingo-oophoro-cystectomy ; left salpingo-oophorectomy. 

The specimen consists of the uterus which has been amputated 
through the cervix. It measures 7 by 7 by 6 cm. and is everywhere 
covered with adhesions. Just posterior to the utero-ovarian liga- 
ment is a myoma 15 cm. in diameter. The anterior uterine wall is 
dense and varies from 1.5 to 2.5 cm. in thickness. The posterior 
wall is also dense and slightly thicker. In the fundus is a myoma 
somewhat diffuse in character, 1.5 cm. in diameter. The uterine 
mucosa is very thin. 

The right tube is bound down by adhesions, but its fimbriated 
end is patent. The right ovar}^ is converted into a cyst approxi- 
mately 6 cm. in diameter. This is likewise covered with adhesions. 

Sections from the anterior uterine wall show that the surface is 
ragged, suggesting that the curette has previously been used. The 
mucosa is dense and the glands are flattened and several are running 
at right angles to the surface. The stroma of the mucosa is appa- 
rently normal. Just beneath the mucosa the tissue is definitely myo- 
matous, being divided up into large and small bundles, and between 
these are isolated glands. In some places the mucosa 
can be traced down into this myomatous tis- 
sue, and cross-sections of isolated glands accompanied by stroma 
can be seen at least 1 cm. from the mucosa. In the posterior wall 
the mucosa presents essentially the same picture as in the anterior. 
There is, however, little tendencj' for the mucosa to extend into the 
depth, except here and there, where isolated glands project down 
into the myomatous muscle. 

We have here a definite adenomyomatous thickening of the 
posterior wall with commencing adenomyoma; dense adhesions 
covering the uterus; a few discrete myomata and general pelvic 
adhesions with a small Graafian follicle cyst on the right side. 

Gyn. No. 12,841. Path. No. 9744. 
Subperitoneal, interstitial, and submu- 
cous uterine myomata. Commencing adeno- 



84 ADENOMYOMA OF THE UTERUS 

myoma; general pelvic adhesions; old sal- 
pingitis. 

A. R., single, aged forty-three, white. Admitted April 13, 1906; 
discharged May 17, 1906. The patient entered the hospital com- 
plaining of a tumor of the uterus and irregular menstruation. Her 
menses commenced at fifteen, were regular, lasting from two to 
three days. For the past year they have been somewhat irregular 
and were prolonged a day or two longer than usual, associated with 
some pelvic discomfort, and pain in the leg. For the last two or 
three years she has had some slight leucorrhoea. Urination was 
somewhat frequent and there was dysuria for a time five or six 
months ago. At that time it was necessary to catheterize the 
patient. Three and a half years ago the patient had a slight uterine 
prolapsus. About seven months ago she had what was said to 
have been " inflammation of the bowels" lasting some weeks. 

Operation . — On entering the abdomen it was found that 
the bladder extended half-way to the umbilicus and the pelvic 
tumor was so adherent that its release was exceedingly difficult. 
During the manipulation a tear was made in the outer coat of the 
rectum. The tear was 2| inches long and about Ih inches broad. 
The surfaces were brought together with fine black silk. The 
highest post-operative temperature was 101.5° F., on the third day. 
The patient made a satisfactory recovery and was discharged on 
May 17, 1906. 

Path. No. 9744 . — The specimen consists of a myoma- 
tous uterus, 8 by 8 by 5 cm. Projecting from the anterior surface 
is a pedunculated nodule 3 cm. in diameter and another 1 cm. in 
diameter. Scattered throughout the uterine walls are several 
myomatous nodules, the largest being about 3 cm. in diameter. 
Attached to the posterior surface of the uterus over almost its entire 
extent is an irregularly lobulated tumor, 17 by 12 by 12 cm. It is 
covered with dense adhesions and on the surface is apparently be- 
coming necrotic. The uterine walls average about 2 cm. in thick- 
ness. The mucosa has not been well preserved. 

Sections from the mucosa show that the surface epithelium is 



DIFFUSE ADENOMYOMA OF THE UTERUS 85 

intact. There is a moderate amount of gland hypertrophy and also 
some polypoid formation. The mucosa shows a distinct tendency 
to project into the depth. We have at one point an area that stains 
sharply with eosin and which might very readily be mistaken for 
an area of necrosis or for a recent tubercle. Examination with the 
high power shows no resemblance to tuberculosis. 

A section from one of the myomata shows a great deal of hyaline 
degeneration and commencing liquefaction. The tube shows evi- 
dence of chronic inflammation. 

Diagnosis . — Subperitoneal, interstitial, and submucous 
uterine myomata; a practically normal uterine mucosa with a dis- 
tinct tendency to penetrate into the depth ; general pelvic adhesions ; 
old salpingitis. 

Gyn. No. 9788. Path. No. 6008. 

Diffuse adenomyoma of the anterior wall 
and fundus and diffuse thickening of the pos- 
terior wall with but little tendency for the 
glands to invade the muscle. 

E. S., aged thirty-two, white, married. Complaint: '' Bearing- 
down" in the lower abdomen and uterine hemorrhage. The menses 
began at fifteen, were regular, lasting from five to six days, but not 
profuse. The patient had some pain with her periods until after 
the birth of her child seven years ago. Since December, 1900, she 
has had several severe hemorrhages at the time of her periods. 
She has been married eight years, has had one child, but no mis- 
carriages. Profuse leucorrhoea has been present for the last year. 
In December, 1900, the patient had a severe hemorrhage which 
started at the time of the regular period and lasted for six weeks. 
She was in bed for four weeks after this. She had slight hemorrhage 
at the time of the period in February, 1902, when for a week she had 
a very profuse flooding, but not so severe as the first time. Since 
February the patient has had almost constant but very slight bleed- 
ing. This is apparently brought on by exertion. For two or three 
weeks the patient has had a good deal of bearing-down pain, which 



86 ADENOMYOMA OF THE UTERUS 

is partially relieved by lying down. She is in a good condition, but 
shows slight pallor of the mucous membranes. 

Operation . — Hystero-myomectomy ; left salpingo-oophor- 
ectomy; right salpingectomy. The patient made an uninterrupted 
recovery. 

Path. No. 6008 . — The uterus has been amputated through 
the cervix. It is 9 cm. in length and nearly 9 cm. in breadth. The 
uterine mucosa has been almost entirely curetted away, but near 
the right cornu some of the thickened mucosa still remains. The 
uterine walls, both anteriorly and posteriorly, show diffuse myo- 
matous thickening. They vary from 3.5 to 4.5 cm. in thickness. 

The appendages are normal. 

On histological examination the uterine glands show some hyper- 
trophy. The diffuse growth in the anterior wall 
has everywhere been invaded by islands of 
uterine mucosa. The glands composing these are for the 
most part normal, but in some places there is moderate dilatation. 
The uterine mucosa can be seen extending 
down in large quantities into this diffuse 
growth, and there is no doubt that the gland elements are 
derivatives from those of the mucosa. 

Sections from the fundus and from the upper part of the pos- 
terior wall also show infiltration with islands of mucosa. In the 
lower part of the posterior wall is a diffuse thickening, but there is 
little tendency for the glands to penetrate into the depth. 

Gyn. No. 10,519. Path. No. 6754. 

Diffuse adenomyoma of the uterus, the 
glands originating from the mucosa. 

S. R., single, aged forty-nine, white. Admitted May 29, 1903; 
discharged June 17, 1903. Complaint: Dysmenorrhoea. Her 
menses are regular, always painful. The patient had no bleeding 
from October to December, 1902. Then the periods were regular 
for five months. For the last three months there has been a foul 
yellowish discharge. At times, since the bleeding commenced, the 



DIFFUSE ADENOMYOMA OF THE UTERUS 87 

patient has had difficulty in holding her urine. For the last three 
years the pains at the periods have Vjeen much worse, not onh^ in 
the back but in both legs and groins. Haemoglobin 50 per cent. 

Operation . — Hystero-salpingo-oophorectomy. The patient 
made a satisfactory recover^^ and was discharged on the twentieth 
day. 

Path. No. 6754 .—The specimen consists of a very evenly 
enlarged uterus with the tubes and ovaries attached. The uterus 
is rather dense and hard. It measures 7.5 cm. in length, 4 cm. in 
breadth. The uterine mucosa in places presents a polypoid ap- 
pearance. This is especially seen in the vicinity of the internal os. 
The uterine walls have a coarsely striated appearance and there are 
little openings, suggesting the gland-like spaces of an adenomyoma. 
The thickening is uniform in both the anterior and posterior walls. 

The tubes and ovaries appear normal. 

Histological Examination . — Sections from the 
body of the uterus show that the mucosa is perfectly normal, that 
it is much thickened, and in numerous places there is a tendency for 
the mucosa to penetrate into the depth. In the inner zone of the 
uterus, where the diffuse thickening is noted, the tissue is 
myomatous, and scattered throughout this 
are islands of uterine mucosa similar to those found 
in an adenomyoma. One cm. from the outer surface of the uterus 
is a miniature cavity 4 mm. in diameter. At other points there are 
dilated glands filled with old hemorrhage. There is no doubt that 
the glands in this case have originated from the mucosa. 

Diagnosis . — Diffuse adenomyoma of the anterior and 
posterior uterine walls; normal appendages. 



CHAPTER IV 

CASES OF ADENOMYOMA IN WHICH THE UTERUS RETAINS A RELA- 
TIVELY NORMAL CONTOUR-(Continued) 

Gyn. No. 7569. Path. No. 3903. 

Diffuse a d e n o m y o m a of the anterior and 
posterior uterine walls, most pronounced in 
the fundus and posterior wall (Figs. 27, 28, and 29) . 

L. C, married, white, aged forty-six. Admitted February 12, 
discharged April 26, 1900. The patient complained of discharge 
of urine through the vagina and of incontinence of feces. Her 
mother, who died of leprosy at the age of forty-seven, had two chil- 
dren while suffering from this disease. Both are living and well. 

When the patient was twelve years of age she had rheumatism, 
and since that time has complained of shortness of breath. At 
twenty years of age she had a second attack of rheumatism. 

Her menses commenced at sixteen, were regular every four weeks, 
lasting four days. The flow, however, was accompanied by pain 
and she had to remain in bed for two days. The flow has always 
been profuse. For the last two years the menstrual periods have 
been painful and irregular ; sometimes an interval of two months will 
elapse. There has been no change in the character of the flow. Her 
last period came on on December 24, 1899. The previous period 
had occurred two months before. 

The patient was married at nineteen and had two children, both 
stillborn, no miscarriages. She had convulsions at the onset of the 
first labor twenty-five years ago and was badty torn. At the second 
labor, twenty-three years ago, there was a complete tear in which the 
bladder was implicated. Ever since the birth of her first child the 
patient has been suffering from incontinence of feces. The condition 
was not improved after the birth of the second child. At that time 
a vesicovaginal fistula developed. Nineteen years ago the patient 



DIFFUSE ADENOMYOMA OF THE UTERUS 89 

was operated upon and an attempt was made to close the fistula with 
silver wire. A second attempt was made two years later, but both 
were unsuccessful. 

Following the birth of the second child the patient had phlebitis 
of the left leg. The leg has since been more or less swollen and at 
times painful. 

Apart from a presystolic murmur at the apex of the heart the 
thorax is clear. Both labia minora and majora are inflamed, ap- 
parently owing to the escape of urine. Protruding from the vagina 
is what appears to be a rectocele. The perineum shows a complete 
tear extending 4 or 5 cm. into the rectovaginal septum. The mucosa 
over the rectum protrudes slightly and is very red in appearance. 
In the upper part of the anterior wall, about 1 cm. from the cervix, 
is a scar which extends across the vagina, and at the left angle of 
the scar is a vesicovaginal fistula. The cervix is deeply lacerated. 
The external os is patulous. 

February 14th. Aniline solution and methylene-blue were used 
to determine the condition of the ureters and the relation of the 
fistula to the left ureter and the bladder. 

Diagnosis : A left ureteral fistula into the vagina and a vesico- 
vaginal fistula; also a rupture of the rectovaginal septum. 

February 19th. The ureter was cut around on all sides and 
turned into the bladder. The rectovaginal septum was restored. 

March 11th. The stitches were removed from the vesicovaginal 
fistula. They were covered with incrustations. An area of granu- 
lation 4 cm. long was found with urine escaping from it. The site 
of operation for complete tear was entirely separated except for the 
two triangular areas in the vagina. 

An opening was now made into the peritoneal cavity. The 
uterus was found to be myomatous and the tubes and ovaries were 
adherent. The uterus, the left tube and left ovary were removed 
in the usual way. The ureter was then turned into the bladder and 
the vesicovaginal fistula repaired. 

Convalescence was slow and the patient complained of much 



90 



ADENOMYOMA OF THE UTERUS 




discomfort, especially of nausea and vomiting. There was con- 
siderable vaginal pain. 

March 30th. She had a chill, the temperature rising to 102.8° F. 
On April 6th she developed phlebitis in the right leg. 

April 24th. The fistulous 
tract in the abdominal incision 
appears to have entirely closed. 
The perineum is in the same 
condition as at the time of ad- 
mission. The uretero vaginal 
fistula appears to have been 
converted into a vesicovaginal 
fistula. The patient was dis- 
charged on April 26th. 

Gyn.-Path. No. 
3 9 3 . — The specimen con- 
sists of the uterus with its left 
appendages. The uterus, which 
has been amputated at the cer- 
vix, is 8 cm. in length, 6.5 cm. 
in breadth, and 5.5 cm. in 
its antero-posterior diameter. 
The anterior surface is smooth 
and glistening. The posterior 
aspect is covered with a few 
adhesions. At the fundus is a 
slightly rounded boss, 3 cm. in 
diameter. The uterine cavity 
is 2.5 cm. in length and at 




Fig. 27. — Diffuse adenomyoma of the body 
OF THE UTERUS. (Natural size.) 

Gyn.-Path. No. 3903. The uterus 
has been amputated through the cervix. Occupy- 
ing nearly the entire body of the organ is a diffuse 
myomatous growth. In the upper part all trace 
of the normal muscle has disappeared except at b. 
Downward the growth can be traced to a and a'. 
The myomatous portion is composed of coarse 
bands of tissue passing in all directions and often 
forming definite whorls with small round or 
irregular cavities in their centres. Some of these 
cavities are cross-sections of blood-vessels; others 
are small cysts. The portion of the uterine cavity 
seen presents the normal appearance and the mu- 
cosa shows no change. For the histological pic- 
ture see Figs. 28 and 29. 



the fundus 3.5 cm. in breadth. 
The anterior uterine wall averages 2.5 cm. in thickness and in 
its inner portion is slightly coarse in texture. The posterior 
wall varies from 2.5 to 3.5 cm. in thickness and from the 
peritoneal surface to the mucosa is coarsely striated, resembling 
diffuse myomatous tissue (Fig. 27). Scattered through- 



DIFFUSE ADENOMYOMA OF THE UTERUS 

this coarse tissue 



91 



out this coarse tissue are small cyst-like 
spaces, some reaching 1 mm. in diameter. 
No definite myomatous foci can be found. 

The left tube and ovary are covered with adhesions. 

Histological Examination . — The uterine mucosa 
has an intact surface epithelium which in some places is considerably 




e d 

Fig. 28. — Extension of the mucosa into the muscle in a case of diffuse adenomyoma 

OF THE uterus. (50 diameters.) 

Gyn.-Path. No. 3903. The section is from the body of the uterus in Fig. 27. 
a represents the thickness of the mucosa which is smooth save for the slight projection b. The 
uterine glands are normal in appearance and the stroma is dense, resembling that normally found 
after the menopause. The mucous membrane is extending en masse into the myomatous tissue 
and can be followed as far as c. d is a small tuft of myomatous muscle almost completely en- 
circled by mucosa, e is an isolated gland in the muscle and partially surrounded by the char- 
acteristic stroma. / is a vein. 

flattened. The mucosa is thin and its glands are very small, re- 
sembling those seen after the menopause. The gland epithelium 
is everywhere intact and normal. The stroma of the mucosa, as 
in old individuals, is very dense. The coarse and striated appearance 
of both uterine walls, more particularly of the posterior, is due to 
an almost complete myomatous transformation of the uterine muscle. 
As a matter of fact, in the posterior wall this diffuse myomatous 



92 



ADENOMYOMA OF THE UTERUS 



condition can be followed to the peritoneal surface. The uter- 



ine mucosa in both the 




Fig. 29. — Method of pexetr.\tion of a single 
uterine gland into the diffu.se myomatous 
GROWTH OF AN ADENOMYOMA. (30 diameters.) 

Gyn.-Path. No. 3903. The section 
is from the body of the uterus seen in Fig. 27; in the 
upper part of the field is the uterine mucosa, the 
lower Hmits of which are represented by a. The 
glands present the normal appearance, but the 
stroma around some of them is pale-staining, while 
that in the vicinity is denser than usual. There is, 
however, no evidence of inflammation. At b are 
cross-sections of two small glands. The origin of 
such glands is indicated by c, where we have a 
longitudinal section of one commencing in the mu- 
cosa and penetrating the myomatous muscle. It is 
lost for a space, but again recognized at c'. Near 
the mucosa it seems devoid of stroma, but in the 
deeper portions it is partially surrounded by stro- 
ma, d is a vein. 



anterior and poste- 
rior walls dips down 
at many points into 
this myomatous tis- 
sue (Fig. 28). In the an- 
terior wall it is possible to 
trace an individual gland 3 
mm. into the depth (Fig. 29). 
In the posterior wall a similar 
extension of the mucosa into 
the myomatous tissue is 
demonstrable, and scattered 
ever^^where throughout the 
posterior wall, but more par- 
ticularly at the fundus and 
extending almost to 
the peritoneal sur- 
face, are islands of 
mucous membrane. 
In this particular case they 
are ver}^ small, individual 
islands rarely containing more 
than two glands with their 
surrounding stroma. These 
glands resemble typical uter- 
ine glands and their stroma is 
identical with that of the mu- 
cosa. Some of the glands are 
dilated and irregular, and 
form the cyst-like spaces noted 
macroscopically. Where the 
glands are moderately dilated 
their epithelium frequently 
stains quite palely. Occasion- 



DIFFUSE ADENOMYOMA OF THE UTERUS 93 

ally an island of stroma is found devoid of gland elements, and now 
and then a small gland is seen devoid of stroma and lying directly 
between muscle bundles. 

In this case we have a diffuse myomatous transformation of 
both uterine walls, but more pronounced in the posterior. Normal 
uterine mucosa has grown into this diffuse myomatous tissue, pro- 
ducing the typical picture of adenomyoma. This case demonstrates 
very well the ease with which the connection between the uterine 
mucosa and the glands in the depth can be overlooked. We ex- 
amined section after section without finding this down-growth, but 
the study of further tissue showed us the direct connection between 
the mucosa lining the uterine cavity and that situated in the myo- 
matous tissue. 

Diagnosis . — ^Diffuse adenomyoma of the anterior and pos- 
terior uterine walls most pronounced in the fundus and posterior 
wall; slight pelvic peritonitis. 

Gyn. No. 2699. Path. No. 246. 

Interstitial and submucous uterine myo- 
mata; slight d i f f u s e a d e n o my o m a t o u s thick- 
ening of the uterine wall with the glands 
originating in the mucosa; small cyst of the 
ovary. 

S. L., married, white, aged fifty. Admitted April 5, 1894; dis- 
charged May 11, 1894. Married at forty-eight. She probably had 
a miscarriage several months after. The menses appeared at four- 
teen, always regular, profuse, although somewhat more so for the 
last three or four years. The patient has had a slight leucorrhoeal 
discharge. Eight months ago a small tumor was noted in the left 
lower abdomen. It has been gradually increasing since then. She 
complains of weakness and of backache. 

Operation . — Hystero-myomectomy. For the first forty- 
eight hours after operation she had almost constant nausea. Her 
temperature was 100.8° F. on the second day. She made a satis- 
factory recovery. 



94 ADENOMYOMA OF THE UTERUS 

Path. No. 246 . — The specimen consists of the enlarged 
uterus with the tubes and ovaries attached. The uterus measures 
16 by 17 by 14 cm., is irregular in outline, smooth and glistening. 
Its under cut surface measures 13 by 11 by 11 cm. Attached to the 
right side of the cervix is a somewhat irregular tumor, 7 cm. in 
diameter. It is firm and non-yielding. To the left of the cervix a 
similar nodule 6 cm. in diameter is found, and the fundus is occupied 
by a tumor, 10 cm. in diameter. 

The cut surface of this tumor presents a somewhat striated ap- 
pearance. It is pearly white in color and very hard in consistency. 
The other nodules are similar in character and all of them are covered 
with a layer of muscle about 2 mm. in thickness. Scattered through- 
out the uterine walls are other smaller and similar nodules, while 
projecting into the uterine cavity is a tumor mass, 7 cm. in diameter. 
The uterine cavity is 6 cm. in length. Its mucosa averages 1 mm. 
in thickness; it is pale and glistening. Over the submucous nodules 
it appears atrophic. At the fundus is a broad based polyp, 1 cm. 
in diameter. Here the mucous membrane is dark red and in- 
jected. 

Histological Examination . — The mucous mem- 
brane over the large submucous nodule is somewhat atrophic and 
the glands are moderately dilated. Their epithelium is intact and 
their lumina contain a pink-grayish material. The stroma is very- 
lax and is made up of cells having round or oval nuclei. The blood- 
vessels of the stroma are very abundant and in several places red 
corpuscles have escaped into the tissue. As one passes toward the 
fundus the glands in the depth are seen to run parallel with the 
surface instead of at right angles to it. A few lymph-nodules are 
found in the muscular coat of the stroma. At the fundus 
the mucosa penetrates into the muscular coat 
for a distance of 3 mm. The glands are not typical, 
but appear as cavities filled with epithelial cells and the muscle 
shows a distinct myomatous tendency. All the nodules scattered 
throughout the uterus are composed of non-striated muscle fibres 
cut longitudinally and transversely. There are areas of hj^aline 



DIFFUSE ADENOMYOMA OF THE UTERUS 95 

degeneration scattered here and there throughout the myomatous 
tissue. 

Both tubes are normal. The right ovary contains a Graafian 
folHcle cyst 2 cm. in diameter. The left ovary contains a cyst 3.5 
cm. in diameter, the exact nature of which it is impossible to deter- 
mine. 

Diagnosis . — Interstitial and submucous uterine myomata; 
small cysts of both ovaries; commencing diffuse adenomyoma. 

Gyn. No. 12,944. Path. No. 9970. 

Diffuse adenomyomata of both the anterior 
and posterior uterine walls with the gland 
elements coming from the uterine mucosa 
(Fig. 30). 

Mrs. B. D., aged thirty-three, white. Admitted May 19, 1906; 
discharged June 19, 1906. The patient entered complaining of 
too frequent menstruation with pain in the back and lower abdo- 
men. She has been a chronic invalid for ten years. She had entered 
the hospital on April 13, 1904. The cervix was repaired, the 
perineum restored, and the uterus dilated. She was discharged 
much improved. At that time the menses occurred every two weeks 
and lasted from six to eight days, and were accompanied with severe 
pain in the back and lower abdomen. Two months after leaving 
the hospital all the patient's former symptoms returned, and since 
that time she has had her menses every two weeks, lasting from 
ten to twelve days, and accompanied by severe pain in the back 
and lower abdomen. She passes large clots at times and the flow 
is very excessive. The patient is incapacitated on account of the 
pain and profuse flow, which weakens her greatly. She has numer- 
ous varicose veins about the ankles and the legs swell at times. 

There is much adipose tissue in the abdomen; some increase in 
resistance in the median line. The outlet is moderately relaxed; 
the cervix is low; the fundus is slightly irregular in outline, enlarged, 
about the size of a three-months pregnancy. There is no tenderness 
laterally. The uterus was removed in the usual way. The ap- 



96 



ADENOMYOMA OF THE UTERUS 



pendix, which was partially obliterated over its base, was also re- 
moved. The patient made a satisfactory recover}^ The highest 
temperature was 101° F., twenty-four hours after the operation. 







f — 



e -- 




A..Mfy^ 



Fig. 30. — Diffuse .\dexomyoma of the body of the uterus. (6 diameters.) 

Gyn.-Path. No. 9970. The section embraces the upper part of the uterine cavity, 
a and h indicate the relatively normal thickness of the mucosa. The ragged inner surface is due to 
a recent curettage. The mucosa is everywhere much thickened and is extending into the under- 
lying myomatous muscle. This down-growth is strikingly well seen at c, and is also extensive at 
</, e, and /. At g there is marked thickening of the mucosa as well as an invasion of the muscle. 
At no point do the glands appear abnormal. 



Path. No. 9970 . — The specimen comprises the uterus, 
appendages, and the appendix. The uterus is approximately twice 



DIFFUSE ADENOMYOMA OF THE UTERUS 97 

the natural size, measuring 9 cm. in length, 9 cm. in breadth, and 6 
cm. in thickness. Both the anterior and posterior 
walls show diffuse myomatous thickening, 
and here and there throughout the myomatous 
areas are little cyst-like spaces. Macroscopically 
it looks very much as if we are dealing with an adenomyoma. 
The anterior wall varies from 2 to 3 cm. in thickness. The 
posterior wall also reaches 3 cm. in thickness. The uterine 
mucosa is apparently considerably thinned out, being not over 1 mm. 
in thickness. 

The tubes and ovaries are apparently normal. 

Histological Examination . — The uterine mucosa 
is of the normal thickness and is rather dense. The glands present 
the usual appearance and the underlying muscle shows diffuse myo- 
matous thickening. The glands flow down into the 
depth from both the anterior and posterior 
walls (Fig. 30). They can be traced for a considerable distance. 
The mucosa extends down like little bays into the depth. In some 
places we have miniature uterine cavities. In the islands of mucosa 
the glands show a good deal of dilatation. We have here, both in 
the anterior and posterior walls, diffuse adenomyoma with the gland 
elements coming from the uterine mucosa and diminishing as one 
passes outward toward the peritoneal surface. 

Gyn. No. 4364. Path. No. 1170. 

Diffuse adenomyoma of the anterior uter- 
ine wall; interstitial uterine myomata; dila- 
tation of uterine glands; uterine polypi; very 
large adenocystoma of the left ovary; gener- 
al p e 1 V i c a d h e s i o n s . H y s t e r e c t o m y a n d c y s t - 
ectomy. Recovery. 

M. H., aged fifty-nine, white, married. Admitted May 8, 1896; 
discharged June 12, 1896. Complaint: Abdominal tumor. The 
patient has had three children ; no miscarriages. The menses began 
at fourteen and were regular until ten years ago. She has always 



98 ADENOMYOMA OF THE UTERUS 

had severe dysmenorrhoea, beginning two days before the period 
and lasting until the flow was fully established. The menopause 
occurred ten years ago. Two years ago she had a profuse hemor- 
rhage from the uterus lasting three days. She has had no leucor- 
rhoea. The bowels are constipated; micturition is frequent. Oper- 
ation, May 12, 1896. Cystectomy and hysterectomy. The ovarian 
cyst was intimately adherent to the surrounding structures and was 
removed with difficulty. The uterus was then amputated through 
its cervical portion. The patient made an uneventful recovery. 

Gyn.-Path. No. 1170 . — The uterus measures 6 by 
7 by 4 cm. Its surface is covered with dense vascular adhesions. 
The anterior wall varies from 3 to 4 cm. in thickness and is very 
coarse in texture. The fundus is also somewhat thicker than usual. 
The posterior uterine wall averages 1.8 cm. in thickness and in the 
vicinity of the cervix contains two interstitial uterine myomata .6 
and .5 cm. in diameter. The uterine cavity is 6 cm. in length and at 
the fundus 4 cm. in breadth. The mucosa is smooth and glistening, 
but contains numerous slightly dilated glands. Springing from 
the anterior wall are two small polypi: the one, 5 by 3 mm., also 
containing dilated glands; the other, a tongue-like process, 8 mm. 
in length and scarcely 1 mm. in thickness. This slender polyp is 
markedly hemorrhagic, especially at its tip, and contains dilated 
glands. 

Left side : The Fallopian tube is 6 cm. in length, 5 mm. in diam- 
eter, and covered with adhesions. 

The cyst removed is multilocular and measures 42 by 34 by 22 
cm. It is pinkish or bluish-gray in color and covered by numerous 
adhesions. 

Histological Examination . — The epithelium cov- 
ering the surface of the mucosa has been poorly preserved, but 
is intact and normal. The mucosa presents a wavy outline and in 
places is gathered up into small polypoid projections or into definite 
polypi. The uterine glands are fairly abundant; some are small 
and tubular and frequently present forked extremities, but many 
of them are dilated, reaching 2 mm. or more in size. The stroma 



DIFFUSE ADENOMYOMA OF THE UTERUS 99 

is in some places denser than usual. The muscle of the anterior 
uterine wall is dense, resembling myomatous tissue, and scattered 
throughout it are glands occurring singly or in groups. Although 
the outer uterine walls are considerably mutilated, these glands 
can be traced laterally to the broad ligament attachment. They 
are lined with one layer of epithelium, are identical with uterine 
glands, and are surrounded by a stroma, similar to that of the uterine 
mucosa. Some of the glands are moderately dilated and at o n e 
point in the depth of the muscle there is a 
miniature uterine cavity, there being sur- 
face epithelium lining the cavity and numer- 
ous glands opening into it, while lying be- 
tween the glands is a typical stroma. At 
some points the uterine mucosa can be traced 
into the myomatous tissue for a distance of 
3 mm. or more. The glands in the depth evidently arise from 
the uterine mucosa. The uterine muscle shows little degeneration, 
but quite a number of its blood-vessels are undergoing obliterative 
changes, and some of them contain calcareous plates beneath the 
intima. 

The multilocular ovarian cyst has connective-tissue walls and the 
inner surfaces of the cyst are lined with one layer of high cylindrical 
epithelium; in other words, it presents the typical appearance. 

Diagnosis . — Diffuse adenomyoma involving the anterior 
uterine wall. Interstitial uterine myomata. Dilatation of the 
uterine glands. Uterine polypi. Very large adenocystoma of the 
ovary. General pelvic adhesions. 

Church Home and Infirmary (Dr. Hunner). Path. No. 6319. 

Diffuse adenomyoma of the uterine wall 
with the glands coming from the mucosa. 

November 22, 1902. The uterus is considerably enlarged. The 
walls reach 1.5 cm. in thickness. In some places the mucosa forms 
distinct polypoid outgrowths. 

Sections from the endometrium show that it has been curetted 



100 ADENOMYOMA OF THE UTERUS 

and that the mucosa presents a very ragged appearance. Extend- 
ing down into the underlying tissue are uterine glands. These do 
not penetrate singly, but large areas of mucosa flow directly into 
the depth. We are in places able to trace the 
mucosa by continuity 6 mm. into the depth. 
The glands are perfectly normal except for here and there a dilata- 
tion. They are likewise accompanied by normal stroma of the 
mucosa. Where the glands are dilated, the epithelium sometimes 
is pale-staining. The muscular tissue in places presents the typical 
myomatous picture. 

Diagnosis . — Diffuse adenomyoma of the uterus with the 
mucosa flowing directly into the myomatous tissue. 

Gyn. No. 11,120. Path. No. 7351. 

Multinodular myomatous uterus, the no- 
dules being subperitoneal and interstitial. 
Diffuse adenomyoma in the uterine wall; dis- 
crete adenomyoma in the left uterine horn 
with formation of a miniature uterine cavity 
(Figs. 31 and 32). 

E. S., single, aged fifty-one, white. Admitted March 17, 1904; 
discharged April 10, 1904. Complaint : Uterine hemorrhages. The 
patient had inflammatory rheumatism and typhoid fever at twenty- 
six. Her menstrual history has been normal until the present illness. 
For two years the periods have been more profuse than usual, grad- 
ually increasing until now she has very severe hemorrhages. During 
the last year the periods have been two or three weeks apart and 
lasting from one to three weeks. She has lost considerable weight 
and strength. The patient is well nourished but looks anaemic. 

Operation March 21, 1904 . — Hystero-myomectomy . 
Convalescence uneventful. The highest post-operative temperature 
was 100.8° F., which was on the fourth day. 

Path. No. 7351 . — The specimen consists of a myomatous 
uterus with the appendages intact. The uterus measures approx- 
imately 9 by 10 by 10 cm. (Fig. 31). Projecting from the left uterine 



DIFFUSE ADENOMYOMA OF THE UTERUS 



101 



horn is a subperitoneal nodule approximately 6 cm. in diameter. 
There are also several smaller subperitoneal nodules. Occupying 
the anterior wall are two myomata, one 5 cm. the other 2 cm. in 
diameter. On section it is found that the uterine cavity has been 
somewhat mutilated. The nodule in the anterior wall presents the 
usual appearance. 

The growth in the left uterine horn is sharply circumscribed and 




Fig. 31. — Discrete uterine myomata. Diffuse adenomyoma with the glands originating 
FROM the mucosa. Adenomyoma of the left uterine horn, (f natural size.) 

Gyn.-Path. No. 7351. Scattered throughout the uterus are one medium-sized and 
several small myomata. Near the uterine horn is a distinct prominence which on section is seen 
even on macroscopic examination to be a diffuse adenomyoma. Histological examination of the 
uterus shows diffuse adenomyoma with the glands originating from the mucosa. For a longitu- 
dinal section of the uterus between points a and h see Fig. 32. 



has on its margin two or three smaller ones. This myoma 
is diffuse in character and has scattered 
throughout it whitish-yellow porous areas, 
evidently islands of uterine mucosa, and at one 
point a cystic dilatation 1 cm. in diameter (Fig. 32), lined with a 
definite membrane and filled with a brown putty-like material. 
In the hardened specimen the uterine mucosa can be seen 



102 



ADENOMYOMA OF THE UTERUS 



lit. cavity 



macroscopically penetrating into the myoma, the mucosa ex- 
tending- into the myoma fully 6 mm. Surround- 
ing the outer surface of the myoma is a zone of normal muscle 
varying from 3 to 6 mm. in thickness. 

On histological examination the endometrium is found to be 

much thickened. The 
surface epithelium is in- 
tact. The majority of 
the glands are normal. 
A few of them, however, 
are dilated. The mu- 
cosa shows a tendency 
in some places to pene- 
trate the uterine wall 
and at one point can be 
traced into the depth for 
a distance of 4 mm. The 
underlying muscle shows 
several small myomata 
scattered throughout the 
wall. The large porous 
growth occupying the 
left uterine horn is seen 
to contain many islands 
of mucosa. One island 
is 1.8 cm. in length and 
varies from 1 to 4 mm. 
in breadth. The uterine 
mucosa composing these islands differs little from the ordinary 
mucosa. Some of its glands are dilated and contain old blood, 
otherwise it is identical. 

Diagnosis . — Multinodular uterus, the nodules being sub- 
peritoneal and interstitial. Diffuse adenomyoma of the uterine 
walls; discrete adenomyoma in the left uterine horn, containing a 
miniature uterine cavity. 




Fig. 32. — Longitudinal section of discrete myomata; 
discrete adenomyoma near the left uterine 
HORN, (f natural size.) 

Gyn.-Path. No. 7351. Fig. 32 is a longi- 
tudinal of Fig. 31 from point a to b. In the anterior wall 
are sections of two discrete myomata. The posterior wall 
shows slight thickening. The discrete adenomyoma, 
although clearly defined, nevertheless is intimately asso- 
ciated with the surrounding muscle a, and could not be 
shelled out as could the other two myomata. It contains 
cystic spaces as indicated by b. The larger space has a 
definite smooth lining and was filled with yellowish putty- 
like material, — old and inspissated menstrual blood. 



DIFFUSE ADENOMYOMA OF THE UTERUS 103 

H. A. K. Sanitarium No. 2178. Path. No. 9803. 

Small interstitial uterine myomata; very 
early adenomyoma with the mucosa extend- 
ing^ into the depth; slight pelvic adhesions. 

C. S., aged forty-six, white. Admitted May 2, 1906 The 
patient has been married twenty seven years and has had one child 
and one miscarriage. Her menses have always been excessive and 
lately the flow has almost amounted to a flooding. No leucorrhcea. 
The patient has been greatly debilitated from excessive loss of 
blood. 

Operation, May 3d. Hystero-myomectomy, double sal- 
pingo-oophorectomy and appendectomy. This patient had been 
operated upon by Dr. Kelly several years ago and a number of 
myomata had been removed. At that time in addition to the my- 
omata there were many adhesions on the left side and the intestines 
were slightly adherent on the right side. The highest post-operative 
temperature was 101.2° F. The patient made a satisfactory re- 
covery. 

Path. Xo. 9803 . — The uterus, both anteriorly and pos- 
teriorly, is enveloped in adhesions. It is very little increased in size 
and contains three myomata, the largest 1 cm. in diameter. The 
right tube is bound down to the uterus. Its fimbriated end how- 
ever, is free. The ovary is but little altered. The left tube and 
ovary have a few adhesions, but the fimbriated end of the tube is 
normal. 

Sections from the endometrium show that the tissue has been 
very poorly hardened and that the surface epithelium is in few 
places intact. The glands, where preserved, are normal. They 
show a considerable tendency to extend into 
the depth. Sections from the body of the uterus show an 
island of mucosa, 2 mm. in length, a short distance below the normal 
mucosa. The direct continuity with the surface can be traced. 
The muscle beneath the mucosa shows commencing diffuse myo- 
matous transformation. 

Diagnosis . — Small interstitial uterine myomata ; very early 



104 ADENOMYOMA OF THE UTERUS 

diffuse adenomyoma with the mucosa extending into the depth; 
sHffht pelvic adhesions. / 

/ 

Gyn. No. 12,678. Path. No. 9466. 

Subperitoneal, interstitial, and submucous 
uterine myomata; commencing adenomyoma 
with the glands originating from the mucosa. 

A. T., married, aged fifty-three, white. Admitted February 5, 
1906; discharged February 26, 1906. Complaint: Pain at men- 
strual period, menorrhagia, difficulty in voiding. The patient was 
in the hospital ten years ago for nervous prostration. 

Her menses were regular, at first every four weeks, the flow last- 
ing four days and being normal in amount. There has always been 
marked dysmenorrhoea and the patient has remained in bed three 
or four days. There has been a gradual increase in the amount of 
flow for the past ten years. About six weeks ago she noticed a 
marked increase in amount, and from that time to the present the 
flow has been greatly augmented Now the periods last from four- 
teen to eighteen days. The pain is cramp-like and so severe as to 
require morphin at times. Large clots are passed. The patient has 
never had any children. For some time the patient was treated 
for anaemia, the real trouble not being suspected. She has been con- 
stipated for some time and has occasionally had hemorrhoids. There 
is a constant desire to urinate, and a feeling of pressure in the bladder. 
On opening the abdomen a small amount of straw-colored fluid 
escaped. On reaching with the hand down into the pelvis a myo- 
matous mass was with some difficulty delivered. No adhesions were 
present. The uterus was removed from left to right without any 
difficulty. The convalescence was uneventful. 

Path. No. 9466 . — The uterus is irregular in shape, 
measuring approximately 12 by 7 by 9 cm. It is free from ad- 
hesions and contains at least four good-sized myomata, the largest 
reaching 6 cm. in diameter. The uterine cavity is 4.5 cm. in length 
and is much distorted by a submucous myoma 3 cm. in diameter 
which completely fills the cavity. 



DIFFUSE ADENOMYOMA OF THE UTERUS 105 

On histolooical examination we have an intact surface epithe- 
lium, normal glands, with here and there hemorrhage into the stroma. 
We also have a commencing diffuse thicken- 
ing of the anterior uterine wall with a flow- 
ing down of the glands into the depth. In other 
words, the picture is one of a typical commencing adenomyoma. 

Diagnosis . — Subperitoneal, interstitial, and submucous 
uterine myomata; commencing adenomyoma of the anterior uterine 
wall. 

H, A. K. Sanitarium No. 1552. Path. No. 6536. 

Interstitial uterine myomata; marked 
penetration of the uterine mucosa into the 
depth with slight diffuse myomatous ten- 
dency. 

F. McC, white, aged fifty-three. Admitted March 10, 1903; 
discharged April 16, 1903. The patient has had five children. The 
menopause occurred six months ago. 

Operation . — Vaginal hysterectomy ; removal of the left 
tube; repair of perineum and excision of a vaginal cyst. The 
patient made a satisfactory recovery. 

Path. No. 6536 . — The specimen consists of a mutilated, 
bisected uterus. In the uterine walls are small myomata. The 
uterus itself is about normal in size. Sections from the uterine 
wall near the fundus show that the mucosa is normal. At nu- 
merous points, however, the mucosa can be 
seen extending into the underlying tissue 
for a considerable distance, and farther out in the 
muscle are islands of mucosa or individual glands surrounded by a 
small amount of stroma. There is a distinct myomatous tendency, 
as evidenced by the discrete myomata. The uterine walls them- 
selves, however, show little tendency toward diffuse thickening. 
Sections from the discrete myomata show the typical appearance 
and hyaline degeneration. 

Diagnosis . — Interstitial uterine myomata, marked pene- 



106 . ADENOMYOMA OF THE UTERUS 

tration of the uterine mucosa into the depth, with sHght diffuse 
myomatous tendency. 

Gyn. No. 11,363. Path. No. 7593. 

Subperitoneal, interstitial, and submu- 
cous uterine myomata. Diffuse adenomyoma 
in the fundus with the glands coming from 
the mucosa (Fig. 33), slight salpingitis; nor- 
mal ovaries. 

A. L., colored, aged forty-five, married. Admitted June 21, 
1904; discharged July 9, 1904. Complaint: Uterine hemorrhages. 
Four brothers of the patient died of consumption. Her previous 
history is negative. Her menses were normal until four years ago, 
when the menopause occurred. She had one child, thirty years 
ago; two miscarriages about twenty years ago. 

Present illness : Nine months ago — that is, three years and three 
months after the menopause — she commenced to have some slight 
uterine hemorrhage. This has lasted on and off until the present 
time, but was never profuse. No other symptoms. She is well 
nourished. Her lungs are normal. 

Operation . — Hystero-myomectomy. Convalescence nor- 
mal. The highest temperature was 101° F., on the third day. Her 
pulse varied from 110 to 130 for the first three days. She was dis- 
charged on the sixteenth day. 

Path. No. 7593 . — The specimen consists of the uterus 
with the tubes and ovaries attached. The uterus is smooth and 
its anterior surface is covered with several nodular elevations. It 
measures 12.5 by 8.5 by 10 cm. and is rather soft. 

On section it is found to contain submucous, interstitial, and 
subperitoneal myomata. The largest measures 7 by 6 cm. The 
uterine cavity is 7 cm. in length. The mucosa in the lower part of 
the body appears to be atrophic. Near the fundus and projecting 
into the cavity is a polyp 2.5 cm. in length. The uterine walls in 
the vicinity of the fundus are coarsely striated and there is a general 
diffuse myomatous tendency (Fig. 33). From the character of 



DIFFUSE ADENOMYOMA OF THE UTERUS 



107 



the growth we should not be surprised to find that it was an adeno- 
myoma. 

On further examination it is seen that the entire fundus is 
occupied by a diffuse and almost circular myoma which is ap- 




FiG. 33. — Subperitoneal, interstitial and submucous uterine myomata; diffuse adeno- 
MYOMA OF THE ENTIRE FUNDUS, (g natural size.) 

Gyn.-Path. No. 7593. The uterine cavity has been cut in two. In the right 
half several polypi are seen. Scattered throughout the uterine walls are subperitoneal and in- 
terstitial myomata, and at the cervix a fairly large submucous nodule. The uterine muscle in the 
body shows a very coarse diffuse myomatous appearance which instantly suggests adenomyoma. 
The pathological report shows that the uterine glands penetrate this diffuse myomatous tissue. 



proximately 7 cm. in diameter. Scattered throughout 
this are a few spongy areas indicative of mu- 
cosa, and at one point is a definite area of 
mucosa 1 cm. in diameter, surrounded by typical 



108 ADENOMYOMA OF THE UTERUS 

myomatous tissue. At another point just beneath the mucosa is a 
circumscribed myoma in the diffuse growth. This contains three 
or four small cystic spaces. 

On histological examination some dilatation of the glands of 
the endometrium is noticeable, especially where the polyp is present. 
Here many of the glands are fulty four or five times their normal 
size. At numerous points the mucosa is found 
to extend into the underlying tissue. Sections 
a little farther up in the cavity show large areas of mucous mem- 
brane penetrating into the depth, and in the underlying tissue are 
many islands of mucosa differing in no way from the normal except 
for gland dilatation. Some of the dilated glands contain a few 
desquamated epithelial cells. The ovaries are normal. There is 
a slight degree of salpingitis. 

Diagnosis . — Subperitoneal, interstitial, and submucous uter- 
ine myomata; diffuse adenomyoma with the glands coming directly 
from the uterine mucosa. 

Gyn. No. 701 1. Path. No. 3289. 

Multiple uterine myomata; diffuse adeno- 
myoma, the glands originating from the mu- 
cosa. P e r i - o o p h o r i t i s . 

E. B. S., aged thirty-three, white, single. Admitted June 20, 
1899; discharged August 1, 1899. Complaint: Menorrhagia; ab- 
dominal tumor; dysmenorrhoea. The menses began at thirteen 
and were always regular, lasting seven days. There was no severe 
pain, but a cutting sensation in the left side. For over a year the 
flow has been very profuse, amounting to hemorrhages. The bowels 
are, as a rule, constipated. Micturition is frequent. 

Operation, June 24. Hystero-salpingo-oophorectomy. The 
right ovary was left in situ. In addition to the uterus, a calcareous 
nodule was removed from the mesentery of the ileum about 10 cm. 
from the ileocaecal valve. The highest post-operative temperature 
was 100.9° F., on the ninth day. The patient made a satisfactory 
recovery. 



DIFFUSE ADENOMYOMA OF THE UTERUS 109 

Path. No. 3289 . — The specimen consists of the uterus, left 
tube and ovaty, and several myomata, the largest measuring 7.5 
by 5 by 4.5 cm. The uterus independent of some of these large 
nodules measures 9 by 7.5 by 8 cm. Its peritoneal surface is some- 
what injected. The uterine cavity is 6 cm. long, 5 cm. broad. At 
the fundus the walls are approximately 6 cm. in thickness. Small 
myomata are seen scattered throughout them. The mucosa is 3 mm. 
in thickness. Its surface is very irregular owing to the presence of 
submucous myomata. It is, for the most part, smooth and glisten- 
ing. 

The right appendages are covered with adhesions. On the left 
side the tube measures 6 cm. in length, 7 mm. in thickness. It is 
free from adhesions. The ovary measures 5 by 4 by 2.5 cm.; is 
soft and fluctuating, being apparently cystic. It is covered with a 
few vascular adhesions. 

On histological examination sections from the decalcified cal- 
careous nodule (3 by 2.5 by 2 cm.) removed from the mesentery, 
show that it possesses a capsule of fibrous tissue which contains a 
few connective-tissue cells. The centre of the calcareous area is 
practically devoid of cell elements. The nodule appears to be a 
calcified lymph-gland. 

Sections from the uterine wall show dif- 
fuse thickening with direct extension of 
the glands into the depth. 

Diagnosis . — Multiple uterine myomata, subperitoneal, in- 
terstitial, and submucous; diffuse adenomyoma. Pelvic adhesions; 
hydrosalpinx. 

Gyn. No. 7859. Path. No. 4122. 

Multinodular myomatous uterus; diffuse 
adenomyoma of the fundus (Fig. 34), with the 
glands originating from the mucosa; general 
pelvic adhesions; right hsematosalpinx. 

A. B., married, white, aged fifty-two. Admitted May 29, 1900; 
discharged June 30, 1900. Complaint: uterine hemorrhage. The 



110 ADENOMYOMA OF THE UTERUS 

patient has been married thirty-six years, and had one child, thirty- 
five years ago, no miscarriages. Her menses were normal until the 
menopause. The patient has not been in good health for four years. 
She has had shortness of breath and palpitation for the last three 
years and has been having excessive hemorrhages, the bleeding 
lasting from one week to one month. She has lost as much as a basin 
of blood in a few minutes, and has had to go to bed at these times. 
The bleeding always comes on after exertion. There has been no 
pain. She was formerly a robust woman, but has been reduced to 
a condition of great anaemia. The lungs are normal. There is a 
soft systohc murmur over the entire cardiac region. Haemoglo- 
bin 30 per cent. The urine contains a large amount of pus and 
some casts. For the last three years the patient has had a greenish, 
offensive discharge. 

Operation : H3^stero-myomectom3^ At the time of her 
discharge, on June 29th, her haemoglobin was 59 per cent. Just 
about an inch external to the anus was a fistulous opening. This 
probabh^ accounted for her temperature, which on the third day 
rose to 103.5° F. 

Path. No. 4122 . — The specimen consists of an enlarged 
uterus, the right dilated tube and ovar}^, and the left tube and ovary. 
The uterus is converted into a nodular tumor measuring approxi- 
mately 12 by 10 by 10 cm. Its anterior surface is smooth, but pos- 
teriorly it is covered with a few adhesions. The under cut surface is 
3 cm. in diameter. The uterine cavity is 6 cm. in length and 4 cm. 
in breadth at the fundus. The mucosa is smooth, pale and glisten- 
ing, but is gathered up into folds, ridges, or poh'^poid-like masses, 
in places 8 or 9 mm. thick. Situated in the posterior wall, near the 
junction of the cervix and the tube, is an interstitial m3^oma 5 cm. in 
diameter. Other smaller nodules are found in the fundus, just 
beneath the peritoneum. Both the anterior and pos- 
terior walls as well as the fundus are thick- 
ened to an average of 5 cm. (Fig. 34) . This hyper- 
trophy is most marked near the mucosa. Covering the outer surface 
of the uterus is a mantle of normal muscle, 1 cm. thick. The thick- 



DIFFUSE ADENOMYOMA OF THE UTERUS 



111 



ened portion on section shows an unusually coarse arrangement, the 
fibres forming an irregular mesh work, with here and there a whorl- 

Adenomyoma 




Fig. 34. — Discrete myoma of the cervix; diffuse .\dexomyoma of the body of the uterus. 

(Natural size.) 

Gyn.-Path.No.4122. a represents a small portion of the uterine cavity. Situated 
at the cervix is a discrete myoma. The uterine walls are greatly thickened as a result of a diffuse 
myomatous change. Scattered throughout this coarse tissue were large and small yellowish, 
porous areas at once recognized as islands of uterine mucosa. On histological examination the 
uterine mucosa was seen literally pouring into the diffuse myomatous muscle. Covering the 
outer surface is a mantle of normal muscle of varying thickness. 



like arrangement in the interstices, 
are creamy looking areas 



of 



mucosa 



In this meshwork 
evidently islands 
The line of junction between the mucosa and 



112 ADENOMYOMA OF THE UTERUS 

the muscle is poorly defined and the muscle bundles apparently 
extend into the mucosa. 

The right tube is;^converted into a pipe-like cyst. The stem 
itself is about 12 cm. long and varies in diameter from 5 mm. at 
the cornu to 14 cm. at the occluded fimbriated extremity. The 
tube is covered with a few adhesions. Its walls are extremely 
delicate and it contains dark, bluish-black fluid. The ovary is 
small and is covered with adhesions. Situated in the utero-ovarian 
ligament is a myoma, 2.5 cm. in diameter. On the left side the tube 
is 8 cm. long and is covered with adhesions. The ovary is small 
and is also involved in adhesions. 

Histological Examination . — The uterine mucosa 
has an intact surface epithelium, as was noted macroscopically. It 
is much thicker than usual. The gland elements are perfectly 
normal. Extending everywhere into the depth 
are large rivers of mucosa; in fact, the mu- 
cous membrane in the diffuse myoma of the 
fundus is more abundant than that lining the 
uterine cavity. The glands in the depth show a certain 
amount of dilatation, and many of them contain necrotic material. 
The isolated myomatous nodule shows considerable hyaline trans- 
formation. In places this is quite sharply defined and many of the 
remaining bundles stand out in marked contrast, reminding one at 
first sight of a malignant change. The right tube is the seat of a 
hydrosalpinx into which there has been hemorrhage. The ex- 
tensive invasion of the normal uterine mucosa into the myoma 
evidently accounts for the alarming hemorrhages that at times took 
place. We have here a myomatous uterus with discrete myomata 
and a widely diffuse myoma occupying the fundus. There is no 
question as to the origin of the glands. 

Diagnosis . — Multinodular myomatous uterus; diffuse adeno- 
myoma of the fundus with the mucosa literally running into the 
depth. General pelvic adhesions; right hematosalpinx. 



DIFFUSE ADENOMYOMA OF THE UTERUS 113 

Church Home and Infirmary No. 1019. Path. No. 9407. 

Large interstitial and submucous uterine 
m y o m a t a showing hyaline degeneration, es- 
pecially pronounced in the walls of the blood- 
vessels. Diffuse adenomyoma in the walls of 
the uterus, the glands coming from the mucosa. 

W. B., married, aged thirty-nine, white. Admitted January 15, 
1906; discharged February 12, 1906. Complaint: Persistent 
hemorrhage from the uterus. The menses commenced at eleven 
and were normal except that they were rather profuse. The date 
of the last period is uncertain. For the past four months the patient 
has bled continuously, and the bleeding has been especially profuse 
during the last month. She has had no pain. She had two mis- 
carriages thirteen years ago, but has never borne children. On 
pelvic examination a mass is found extending half-way to the um- 
bilicus, occupying the entire superior strait of the pelvis. It is 
rounded in outline and not especially tender. 

Operation : Abdominal hysterectomy. The highest tem- 
perature was 100.8° F., twenty-four hours after the operation. 

Path. No. 9407 . — The specimen consists of the upper 
part of the uterus. It is globular and contains a myoma measuring 
12 by 10 by 10 cm. The uterine cavity measures 7 cm. in length and 
7 cm. in breadth. The mucosa, which is somewhat granular and 
hemorrhagic, is put on tension by a large submucous myoma. This 
on section shows some cystic areas and a moderate degree of de- 
generation. 

Sections from the endometrium show that the mucosa, apart 
from some hemorrhage, is perfectly normal. In some places 
the mucous membrane can be seen extending 
into the depth for a considerable distance-, and 
in the vicinity we have isolated glands or bunches of glands surround- 
ed by stroma, and lying in the depth. The muscle shows a definite 
myomatous tendency. Sections from the myoma show a good deal 
of hyaline degeneration, particularly pronounced around the blood- 
vessels. 



114 ADENOMYOMA OF THE UTERUS 

We have here a large interstitial and partly submucous myoma 
showing hyaline degeneration, and also a fairly well-defined diffuse 
adenomyoma of the body of the uterus with the glands originating 
in the mucosa. 

Gyn. No. 11,252. Path. No. 7507. 

Subperitoneal and interstitial uterine 
myomata; diffuse adenomyoma of the uter- 
ine walls; subperitoneal adenomyoma. 

F. S., colored, aged forty-four. Admitted May 5, 1904; dis- 
charged June 2, 1904. Complaint : Pain in the left side. The patient 
had always had considerable dysmenorrhoea. She had been married 
twenty-one years, but had never been pregnant. She complained of 
a burning discomfort during the first two days of menstruation, and 
for some years had had continued pain in the left ovarian region. 
She was well nourished. Several small myomata were detected 
and the uterus was retroflexed and adherent. It was decided to 
remove the uterus, as the patient was near the menopause and as 
she had come such a long distance for treatment (Jamaica) . 

Operation : Hystero-myomectomy. The highest tempera- 
ture was 100.5° F., on the second day. Convalescence normal. 

Path. No. 7507 . — The uterus has been amputated through 
the cervix and is 4 cm. in length. On the posterior surface is a 
pedunculated myoma, 1 cm. in diameter. Just above this is a 
slight elevation. On section the uterine walls are found to vary 
from 1.5 to 1.8 cm. in thickness. Scattered throughout the uterine 
tissue are a few minute myomata. In the anterior wall about its 
middle is an irregular mass, 1 cm. in diameter. This is not sharply 
circumscribed, but gradually blends with the surrounding uterine 
muscle. 

On histological examination the uterine mucosa shows much 
thickening. The surface epithelium is intact. The stroma cells 
immediately beneath are swollen, somewhat resembling decidual 
cells, and the tissue shows a great deal of small round-cell and poly- 
morphonuclear infiltration. The glands in the depth show marked 



DIFFUSE ADENOMYOMA OF THE UTERUS 115 

hypertrophy and there is a peculiar tendency for 
them individually or in bunches to extend 
quite a distance into the underlying muscle, 
usually accompanied by their stroma. 

The myoma in the anterior wall is diffuse in character and con- 
tains islands of uterine mucosa and also isolated glands, the majority 
of which are associated with the characteristic stroma of the mucosa. 
Some of the glands, however, lie in direct contact with the muscle. 

We have here a uterus smaller than normal, one subperitoneal 
and several interstitial myomata, an endometrium which is thicker 
than usual and which shows definite invasion into the muscle. We 
also have a partially subperitoneal adenomyoma which is somewhat 
diffuse in character and blends with the surrounding muscle. We 
have not the slightest doubt that such a uterus in time would be 
the seat of a wide-spread diffuse adenomyoma. 

H. A. K. Sanitarium No. 1453. Path. No. 6216. 

Diffuse adenomyoma of the anterior and 
posterior uterine walls (Fig. 35) . The gland 
elements are derived from the uterine mu- 
cosa. 

H. C, married, white, aged forty-seven. Admitted October 20, 
1902; discharged December 11, 1902. The patient has had four 
children. Her menses, which were regular, have lately become ir- 
regular and more frequent. 

Operation : Pan-hysterectomy; repair of the perineum; 
removal of a urethral caruncle. The patient made a satisfactory 
recovery. 

Path. No. 6216 . — The uterus is 13 cm. in length, 10 cm. 
in breadth, and 9 cm. in its antero-posterior diameters. Its surface 
is smooth and glistening, except near the fundus. There are a few 
adhesions and the tubes and ovaries are bound down. The uterus 
is about the size of that of a three and a half months' pregnancy. 
The cervical canal, which is curved, is about 3 cm. in length. The 
increase in size of the uterus is due to a marked 



116 



ADENOMYOMA OF THE UTERUS 



diffuse thickening of the anterior wall, which 
reaches 7 cm. in thickness (Fig. 35) . Scattered 
throughout the thickened and diffuse myo- 




FiG. 35. — Diffuse adenomyoma of the body of the uterus. (| natural size.) 

Gyn.-Path. No. 6216. A longitudinal section through the entire uterus. Sur- 
rounding the uterine cavity, which looks normal, is a broad zone of diffuse myomatous tissue, 
much thicker in the anterior than in the posterior wall. Covering this is a mantle of normal 
muscle, a, but at the fundus the coarse myomatous tissue almost reaches the peritoneum. Sec- 
tions show that the uterine mucosa extends into the depth and that many islands of mucous 
membrane are scattered throughout the myomatous tissue. 



matous tissue are a few cystic spaces lined 
with a delicate velvety membrane. The posterior 
uterine wall varies from 2.2 to 2.5 cm. in thickness. Its texture is 



DIFFUSE ADENOMYOMA OF THE UTERUS 117 

also coarse, but the striation is not as marked as in the anterior wall. 
Covering the diffuse growth in both the anterior and posterior wall 
is a mantle of normal uterine muscle. The uterine cavity is small, 
about 4.5 cm. in length. 

On histological examination the uterine mucosa is found to be 
slightly thickened, but otherwise normal. The diffuse thickening 
in the anterior wall is due to a diffuse myomatous transformation of 
the muscle. Scattered abundantly through the 
myomatous muscle are large and small is- 
lands of uterine mucosa. Some of these are fully 8 mm. 
in length. Here and there the glands are dilated; otherwise this 
mucosa differs in no way frorii that lining the uterine cavity, and 
at many points the uterine mucosa can be traced directly into the 
myoma. In the posterior wall there is also a diffuse adenomyoma. 
Here likewise the continuity with the surface mucosa can be traced. 

In this case there is a diffuse mantle of myomatous tissue sur- 
rounding the entire uterine cavity, markedly developed in the 
posterior wall ; and penetrating this mantle are large areas of uterine 
mucosa. 

Diagnosis . — Diffuse adenomyoma of the anterior and 
posterior uterine walls. The gland elements are derived from the 
uterine mucosa. 

Gyn. No. 12,358. Path. No. 8983. 

Subperitoneal, interstitial and submu- 
cous uterine myomata; slight endometritis; 
diffuse adenomyoma with the uterine glands 
extending into the depth; adenomyomatous 
areas in the left uterine horn. 

S. S., aged thirty-one, black, married. Admitted September 11, 
1905; discharged October 2, 1905. Complaint: A painful lump 
in the left side of the abdomen and uterine hemorrhages. The 
menses commenced at thirteen, were always regular but painful, and 
are now profuse. The flow lasts three days. There is some pain 
for twelve hours previous to the flow. She has been married twice. 



118 ADENOMYOMA OF THE UTERUS 

She had one pregnancy six or seven years ago, normal until the 
sixth month, when a premature labor came on as the result of a 
fall. The child was born dead. Nine months ago patient noticed 
a lump in the left side, which has been almost constantly painful. 
She knows nothing about the growth of the tumor. She says that 
the tumor pushes upward and causes discomfort, which she can 
relieve b}^ pressing down upon it with her hand. There have been 
no changes in the menstrual flow until two months ago, when there 
was increased pain and the flow was excessive, but without clots. 
One month ago the period did not appear at the expected time, but 
there was an excessive flow of a clear water}^ fluid. There has been 
much tenderness since she first noticed the tumor. No nausea or 
vomiting. 

Operation : Hystero-myomectom}^ ; double salpingectomy, 
left oophorectomy. The highest post-operative temperature was 
101.4° F. Convalescence was uninterrupted. 

Path. No. 8983 . — The specimen consists of an irregularly 
globular uterus, 12 cm. from side to side, 12 cm. in length, and 14 cm. 
in its antero-posterior diameter. Posteriorly it is covered by tags 
of adhesions, none of which are very dense. In the anterior wall is 
a myoma 7 cm. in diameter. In the posterior wall is a myoma 
measuring 8 by 9 cm. Attached to the right side just behind the 
tube is a nodule 7 cm. in diameter. This is attached by a pedicle, 
2 cm. in breadth, 5 mm. in thickness. This myoma on section 
presents a dark appearance in places and has undergone slight ne- 
crosis. 

The left tube is normal. The ovar^^ is covered with a few ad- 
hesions. The right tube is normal. 

Sections from the endometrium show that it has been poorly 
hardened. The glands show a moderate degree of hypertrophy. 
Here and there they extend for a short distance into the muscle. 
There is some small round-cell infiltration. Sections from the 
fundus, which are better preserved, show considerable small round- 
cell infiltration in the superficial la^^ers, and in the depth far down 
are here and there glands some of which show the characteristic 



DIFFUSE ADENOMYOMA OF THE UTERUS 119 

pseudo-glomeruli described by von Recklinghausen, the spaces being 
Hned with cuboidal epithehum and a projection of stroma into the 
cavity being noted. This projection also is covered with epithelium, 
and in the spaces between this and the so-called capsule is desqua- 
mated epithelium. Near the outer surface the gland-like spaces 
are much more abundant. They are ever^^ where surrounded by 
muscle, and some of the larger spaces reach 2 mm. in diameter. 
They are lined with one layer of cuboidal epithelium which rests 
directly on the muscle. 

On further section of the uterine mucosa we find a tendency 
for the glands to extend into the depth in 
the form of a wedge. Sections taken from near the left 
cornu show that the tube presents some slight degree of small round- 
cell infiltration just beneath the epithelium. Surrounding this in 
many places are glands lined with one layer of epithelium resting 
directly on the muscle, or separated from it by a small amount of 
stroma. Some of the gland-like spaces are dilated, their epithelium 
is flattened, and they are filled partly with blood, partly with serum. 

Diagnosis . — Subperitoneal, interstitial, and submucous 
myomata; slight endometritis; diffuse adenomyoma of the uterine 
wall with invasion of the mucosa into the depth ; adenomyomatous 
areas in the left uterine horn; slight adhesions of the ovaries. 

Emergency Hospital, Frederick, Md. Path. No. 8393. 

Diffuse adenom}^oma of the anterior and 
posterior uterine walls; large cystic spaces 
in the uterine horn due to dilatation of por- 
tions of the adenomyomatous elements (Fig. 
36) . The gland elements in the diffuse growth 
are clearly shown to be derivatives of the 
uterine mucosa. 

V. W., aged fifty-three. Operated upon February 3, 1905. 
The patient has been suffering for some time from a myomatous 
uterus and has had frequent uterine bleeding. On opening the 
abdomen we found a myomatous uterus about the size of that of a 



120 



ADENOMYOMA OF THE UTERUS 



four months' pregnancy. Numerous nodules were present. The 
cervix was adherent. Posteriorly and on the right side was a hy- 
drosalpinx. The tumor was removed with little difficulty and the 
patient made a satisfactory recovery. 

Path. No. 8393 . — -The specimen consists of a large glob- 
ular uterus and of the appendages on both sides. The uterus has 
been amputated through the cervix. It is 12 cm. in length, 15 cm. 
from side to side, and 10 cm. in its antero-posterior diameters. 
Covering its surface posteriorly are a few delicate adhesions. On 




Fig. 36. — Diffuse adexo.myoma of the fundus with cystic spaces in the left uterine 

HORN. (J natural size.) 

Gyn.-Path. No. 8393. The entire fundus is converted into a diffuse myomatous 
tissue and with the low power the uterine mucosa can be seen penetrating the myoma in all 
directions. The cystic space a, in the left uterine horn is due to gland dilatation, it being lined 
with cylindrical ciliated epithelium. The space b is filled with blood. On the right side is a 
tubo-ovarian cyst. The inner pole of the right ovary is normal. 



examination it is found that the thickening in the 
uterus is due to a diffuse myomatous ar- 
rangement around the uterine cavity (Fig. 36) . 
The thickening in both the anterior and the posterior wall reaches 
5 cm. There is likewise a tendenc}^ toward a circumscribed diffuse 
area 2.5 cm. in diameter. The uterine mucosa is apparently consid- 
erably thickened. The general picture instantly reminds one of a 
diffuse adenomyoma occupying both the anterior and the posterior 
wall and encircling the fundus. 



DIFFUSE ADENOMYOMA OF THE UTERUS 121 

In the left uterine cornu is an irregular cystic space, 6 by 4 cm. 
This is partially divided by septa and has delicate trabeculse passing 
from side to side. The cyst walls in the outer portion vary from 
1 to 3 mm. in thickness. The right tube has been converted into a 
hydrosalpinx, which at its outer end is 9 cm. in diameter. The right 
ovary is apparent^ normal. The left tube is enveloped in delicate 
adhesions. Its fimbriated end is patent. The ovary is very small 
and apparently contains a corpus luteum cyst 1 cm. in diameter. 

In the lower portion of the uterus is a myomatous whorl 2 cm. 
in diameter, and near the centre of this is a cystic area 8 mm. in 
diameter filled with yellowish contents. 

Sections from the body of the uterus show that the uterine 
mucosa has not been well preserved owing to faulty hardening. 
It canat several points be traced directly 
into the depth for a considerable distance. 
Scattered abundantly throughout the diffuse myomatous growth, 
in the anterior as well as in the posterior wall, are islands of uterine 
mucosa, sometimes also an individual gland surrounded by stroma, 
and then again an area of mucosa containing imperfectly preserved 
glands. The same picture is noted no matter where the section 
comes from. Where the diffuse myomatous growth ends the glands 
also end. 

Sections from the cyst in the left cornu show that it is lined with 
one layer of ciliated epithelium. The myomatous nodule with the 
cystic centre, containing yellowish material, presents a very in- 
teresting picture. The nodule consists of typical myomatous tissue. 
The cystic space is filled with coagulated contents, fragments of 
nuclei, and a few polymorphonuclear leucocytes, and the walls of 
this cavity, partly organized, contain numerous small round cells. 
This has evidently been a portion of a miniature uterine cavity 
from which the epithelium has disappeared and a partially organized 
blood-clot has taken its place. 

Diagnosis . — Diffuse adenomyoma of the anterior and 
posterior uterine walls; large cystic spaces in the left uterine horn, 
evidently due to dilatation of portions of the adenomyomatous 



122 ADENOMYOMA OF THE UTERUS 

elements. The gland elements in the diffuse growth are clearly 
shown to be derivatives of the uterine mucosa. 

H. A. K. Sanitarium No. 1913. Path. No. 8641. 

Subperitoneal and interstitial uteri ne 
myomata; commencing diffuse adenomyoma 
of the uterine walls; normal appendages. 

McC, white, aged fifty-two, married. Admitted April 27, 1905; 
discharged June 9, 1905. In 1885 the patient had pulmonar^^ 
tuberculosis, a left pyelonephritis, and an infected bladder. 

Present condition: The periods are regular but profuse. The 
patient has had a tumor which has been increasing in size for some 
time. 

Operation : Hystero-myomectom}^ and appendectomy. 
The patient was of a very nervous temperament, but made a satis- 
factory recovery. 

Path. No. 8641 . — The specimen consists of a myomatous 
uterus which would be practically normal in shape were it not for a 
subperitoneal nodule projecting far out from the left side. The 
uterus with the nodule is 9 cm. in length, 8 cm. in breadth, and 1 1 cm. 
in its antero-posterior diameter. It is smooth and glistening. 
Projecting from the posterior surface just behind the insertion of 
the left tube is a mj^omatous nodule approximately 7 cm. in diameter. 
The uterus on section is found to be riddled with myomata. In the 
upper part the nodule is 3 cm. in diameter. The uterine cavity is 
5 cm. in length and the mucosa 2 mm. in thickness. 

The appendages on both sides are normal. 

Sections from the mucosa show that the surface epithelium is 
intact. The glands are normal. There is a tendency 
for the glands to dip down into the depth, and 
here and there it is possible to trace them for 
a considerable distance. Undoubtedly we have here 
a commencing adenomyoma. 

Diagnosis . — Sul^peritoneal and interstitial uterine my- 
omata; commencing diffuse adenomyoma. 



DIFFUSE ADEXOMYOMA OF THE UTERUS 123 

H. A. K. Sanitarium No. 1944. Path. No. 8807. 

^lultiple uterine myomata, su I) peritoneal, 
interstitial, and submucous; diffuse adeno- 
myomatous thickening in the anterior and 
posterior uterine walls with direct exten- 
sion of the uterine mucosa into the depth, 
together with the formation of a miniature 
uterine cavity. 

A. C, married, aged forty-eight. Admitted May 17, 1905. 
Discharged June 21, 1905. The patient has been married twenty- 
two years, has had three children and one miscarriage three years 
ago. The menses are normal. There has been some watery leu- 
corrhoeal discharge. The patient is very frail and has lost somewhat 
in weight. Her haemoglobin is 40 per cent. She has had chronic 
constipation. Her family and previous history are not important. 
For about a year she has noticed that her abdomen has been growing 
rapidly and she has had constant backache. She suffers from fre- 
quent vesical irritation and obstinate constipation. 

Operation, May 18. Hystero-salpingo-oophorectomy. 
After the operation this patient had a slight infection about the 
cervix which caused some elevation in temperature — 100.4° F. on 
one occasion. The temperature gradually subsided. 

Path. No. 8807 . — The specimen consists of a nodular 
myomatous uterus with appendages. The uterus is approximately 
12 cm. in length, 12 cm. in breadth, and 8 cm. in its antero-posterior 
diameters. It is for the most part smooth and glistening. Pro- 
jecting from the surface are pedunculated and sessile myomata, and 
scattered throughout the walls are a few other nodules. Projecting 
from the right side and extending out into the broad ligament is an 
irregular, nodular, myomatous growth, which measures 15 b}' 18 by 
14 cm. This is partly covered by peritoneum, but beneath the 
smooth surface is a good deal of adipose tissue, evidently from the 
broad ligament, and coursing over the anterior surface is the right 
round ligament, which can be traced for a distance of 12 cm. Very 
little of the uterine cavity is to be seen except in the upper portion. 



124. ADENOMYOMA OF THE UTERUS 

The uterine mucosa varies from 2 to 3 mm. in thickness. Three mm. 
beneath the mucosa is a miniature uterine cavity, 4 mm. in diameter, 
filled with coagulated chocolate-colored fluid, and lined with a 
mucosa 1 mm. in thickness. Just beneath the peritoneal surface of 
the uterus are a few cyst-like spaces, the largest 2 mm. in diameter. 
The tubes and ovaries look normal. 

Sections from the fundus show a most instructive picture. The 
surface epithelium is intact. The glands are to a great extent 
normal, but some are much dilated, others skein-like. The mu- 
cosa is flowing down everywhere into the 
underlying tissue. In some places it can be 
traced by direct continuity for 6 or 7 mm. 
The mucosa that flows into the depth is perfect^ normal except for 
here and there some gland dilatation. On the opposite side of the 
cavity we are able to trace the mucous membrane for 1 cm. into 
the underlying myomatous muscle. Here and there a small band 
of mucosa will pass down and then branch out in all directions. 
The brownish area apparently surrounded 
by a definite mucosa and noted macroscopic- 
ally is a miniature uterine cavit}^. This cavity 
is filled with blood and is lined with one layer of high cylindrical 
epithelium. Opening into it are numerous glands surrounded by 
the characteristic stroma of the mucosa. 

Diagnosis . — Multiple uterine mj^omata, subperitoneal, 
interstitial, and submucous; diffuse adenomyoma of both the 
anterior and posterior walls, the gland elements being distinctly 
derivatives of the uterine mucosa. 

The presence of adenomyoma was immediately suspected as soon 
as the chocolate-colored area surrounded by a definite lining of 
mucosa was detected. As a rule, no other condition in the uterus 
would give rise to such a picture. 



CHAPTER V 
SUBPERITONEAL AND INTRALIGAMENTARY ADENOMYOMATA 

Subperitoneal and intraligamentary adenomyomata are con- 
sidered together, inasmuch as the process is similar in both instances, 
namely, the extension to the outer surface of the uterus. If situated 
above the middle of the uterus, the adenomyomata tend to become 
subperitoneal; below this point and lateral to the uterus they are 
likely to spread out between the folds of the broad ligament. 

SUBPERITONEAL ADENOMYOMATA 

Subperitoneal adenomyomata may be very small and com- 
pletely isolated, as seen in Fig. 61, p. 219,^ in which an adenomyoma 
less than 1 cm. in diameter was found in a patient operated upon 
for adenocarcinoma of the body of the uterus. The two processes 
were entirely independent of each other. This small nodule, to the 
unaided eye, differed in no way from an ordinary myomatous nodule. 

Subperitoneal adenomyomata may, on the other hand, be of 
goodly size. Fig. 37 represents a subperitoneal nodule measuring 
13 by 10 by 8 cm. and attached by a broad base. As seen from the 
drawing, it was partly cystic, partty solid. The distal or free portion 
had been converted into a thin-walled and irregular cyst partially 
filled with blood. The solid portion consisted of myomatous tissue 
traversed by several small cysts, some not more than 1 mm. in 
diameter, others are more than 1 cm. On histological examination 
the large cyst was found to be in the vicinity of the solid area, lined 
with one layer of cylindrical epithelium ; but where the walls were 
very tense and thin, the epithelium had become very low or had 
entirely disappeared. In Fig. 38, a low magnification, it is seen 
that the cystic spaces scattered throughout the solid portion are 

^CuUen, Thomas S.: Cancer of the Uterus, 1900, p. 460. 

125 



126 ADENOMYOMA OF THE UTERUS 

dilated glands lined with one layer of cylindrical epithelium. Some 
of these are separated from the muscle by the typical stroma. 

In neither of the foregoing cases was there any evidence of adeno- 
myomata in the body of the uterus. 

In Case 3293 we have another example of a cystic subperitoneal 
adenomyoma. As noted in the history, the uterus was greatly in- 
creased in size, chiefly owing to the presence of a large submucous 
myoma and a huge subperitoneal and pedunculated myoma spring- 
ing from the left side. Projecting from the right side of the fundus 
was a nodule measuring 6 by 5.5 by 5 cm. This was soft and boggy, 
and over an area fully 5 cm. in diameter was made up of thin-walled 
cysts (Fig. 39). On histological examination the cyst walls were 
found to consist of myomatous tissue and the cavities were lined 
with one layer of cjdindrical, ciliated epithelium (Fig. 40). The 
cells closely resembled those of the normal uterine mucosa. In 
some places the walls of the cavity were gathered up into little 
papillary-like folds. In other places, irregular gland-like cavities 
were found scattered throughout the walls. These closely resembled 
the gland hypertrophy so often seen in the uterine mucosa. In a 
few places the walls of the cysts showed evidence of old hemorrhages, 
their cells having taken up large quantities of fine yellow granular 
pigment. Here also we have a subperitoneal adenomyoma with 
elements closely resembling uterine mucosa. 

San. No. 1872 is the most striking example of a subperitoneal 
myoma that we have ever seen. Fig. 41, p. 142, gives the relative 
contour of the uterus. It was the seat of a diffuse adenomyoma. 
At a is a subperitoneal and pedunculated myoma which is partly 
cystic. On section of this subperitoneal nodule we found large 
islands of mucosa, and the cystic areas formed miniature uterine 
cavities filled with chocolate-colored contents. The islands of 
mucosa and also the cystic spaces are depicted in Fig. 42, p. 144. 

Of interest is the case of Neumann.^ In a woman forty-four 

^Neumann, Siegfried: Ueber einen neuen Fall von Adenomyom des Uterus 
und der Tuben mit gleichzeitiger Anwesenheit von Urnierenkeimen im Eierstock. 
Arch. f. Gynaek., 1899, Bd. Iviii, S. 593. 



SUBPERITONEAL AND INTRALIGAMENTARY ADENOMYOMATA 127 

years of age he found an interstitial myoma, the size of a fist, and on 
the anterior surface of the uterus in the vicinity of the cervix a 
subserous myoma, the size of a walnut. Lying in close proximity 
to this was- a cyst as large as a hen's egg. This had a broad base. 
The walls of the cyst were composed of uterine muscle, near the base 
having a thickness of 3 mm., but becoming thinner until at the con- 
vex and free surface the}^ were not thicker than parchment. The 
inner surface of the cyst was smooth and the cavity contained a 
coagulated, friable, grayish mass. In the vicinity of these cysts 
were two others, the size of hazelnuts and with very thin walls. 
Situated in the tissue, at the base of these two, was still another 
cyst about as large as a bean. This was subdivided into several 
smaller cavities. The large cyst had a wall composed of muscular 
tissue and was lined with a single layer of cylindrical ciliated epithe- 
lium. This rested on a connective-tissue stroma, which separated 
it from the muscle. Scattered throughout the myomatous muscle 
were glands bearing a marked resemblance to uterine glands and 
surrounded by stroma similar to that of the uterine mucosa. Neu- 
mann says that this was undoubtedly a large adenomyoma of the 
uterus, cystic in character. There was also an adenomyomatous 
polyp in the uterine cavity and another adenomyoma in one of the 
uterine horns. He was unable to trace any connection between the 
uterine mucosa and the adenomyomata. 

Among the most remarkable subperitoneal adenomyomata of 
the uterus ever reported was the "voluminous" tumor of Pick,^ 
which occurred in a woman forty-one years old, sprang from the 
posterior surface of the uterus, and was adherent to the anterior 
abdominal wall and to the intestinal loops. Landau experienced 
much difficulty in its removal. The tumor, as shown in the illustra- 
tion which Professor Pick kindly sent me, presented a very coarse 
shaggy appearance. It consisted of many large, blunt, papillary 
masses, and in the vicinity of the median line the mass contained a 
glistening, slimy, cystic tumor, about the size of a man's head. It 

^Pick, Ludwig: Ein neuer Typus des voluminosen paroophoralen Adenomy- 
oms. Arch. f. Gynaek., Bd. liv, S. 117. 



128 ADENOMYOMA OF THE UTERUS 

was evetywhere adherent. The cyst cavity contained clear muco- 
colloid material. On the surface of the growth were many isolated 
nodules consisting of myomatous tissue and containing large and 
small spaces. Pick found that the solid portions of the tumor con- 
sisted of a fibromyomatous substance surrounding well-formed 
glandular tissue. This glandular tissue consisted of cylindrical 
glands lined with a single layer of C3dindrical epithelium. Sometimes 
the glands occurred in groups and were surrounded by a definite 
stroma; others showed cystic dilatation. From the description it 
is seen that this tumor w^as a subperitoneal and adherent adeno- 
myoma. 

Cases of Subperitoneal Adenomyoma 
Gyn. No. 8647. Path. No. 4838. 

Diffuse a d e n o m y o m a t o u s thickening of 
the uterine walls; interstitial and subperi- 
toneal myomata; slight edema of the uter- 
ine mucosa with extension of the gl ands into 
the depth. Subperitoneal, cystic adeno- 
myoma. (Figs. 37 and 38.) 

F. M. R., single, aged forty, white. Admitted April 8, discharged 
May 2, 1901. The patient was operated upon for hemorrhoids two 
years ago. Her menses began at twelve and were regular, lasting 
three da3^s. For several years at the menstrual period the patient has 
complained of headache and nausea. There has been no marked 
disturbance of menstruation at any time, but occasionally the period 
has been delayed a few days. The last period occurred one 
week ago. 

The patient does not know when she first noticed a lump in the 
right side of the abdomen. In the beginning it was about the size 
of an egg, but for the last year has been increasing. There has been 
no pain or discomfort associated with it. The general condition 
has been good. 

In the right lower abdomen is a definite prominence. This is 
firm on palpation, distinctly movable, and reaches to a point 2 cm. 



SUBPERITONEAL AND INTRALIGAMENTARY ADENOMYOMATA 129 

below the umbilicus. It is smooth and oblong in shape. The in- 
guinal glands are palpable, but not tender. 

Operation April 10th. — A large multinodular myomatous 
uterus was exposed. The uterus was bisected and removed. The 
tubes were likewise removed, but the ovaries were left in situ. The 
patient was discharged in excellent condition on the twenty-third 
day. 

Gyn.-Path. No. 4838 . — The specimen consists of a 
bisected, multinodular uterus and of both tubes. One nodule, 
which projected from the right cornu and was attached by a pedicle, 
4 cm. in diameter, measures 13 by 10 by 8 cm. Its inner half is 
firm and dense; its outer portion is soft and cystic, but everj^where 
covered with smooth peritoneum (Fig. 37) . On section the solid por- 
tion of this nodule is seen to be made up of typical myomatous tissue, 
but at two points are seen irregular cystic areas 1 and 2 cm. in 
diameter respectively. The smaller of these has a smooth inner 
surface and apparently a definite lining. The large cystic portion 
of the subperitoneal myoma contains a single cavity, approximately 

7 cm. in diameter. The walls of this vary from 1 mm. to 1 cm. in 
thickness; the cavity contains a thick, viscid, chocolate-colored 
substance. The uterus is very irregular in form and has projecting 
from its surface numerous small myomatous nodules. It measures 

8 by 8 by 5 cm. The tubes are apparently normal, but attached to 
the fimbriated extremity of one of them is a subperitoneal cyst meas- 
uring 1.5 by 1 cm. 

Histological Examination . — Sections from the 
uterine cavity show that, where the mucosa has been protected, 
there is an intact surface epithelium, slightly flattened but perfectly 
normal. The uterine glands are normal in number. Near the cavity 
they are narrow, but in the vicinity of the muscle are much convo- 
luted. The gland epithelium is normal. The stroma of the mucosa 
just beneath the surface epithelium shows considerable edema. 
At one point in the uterine cavity the mucosa 
is seen penetrating the muscle to a depth of 
1.5 mm. Here the glands are dilated and surrounded by diffuse 



130 



ADENOMYOMA OF THE UTERUS 



myomatous tissue. The uterine walls show partial myomatous 
transformation of their muscle bundles, and scattered throughout 
the walls are numerous small myomata. Some of these are not 
more than 1 mm. in diameter. 




Fig. 37. — A cystic subperitoneal adexomyoma of the uterus. (Natural size.) 

Gyn.-Path. No. 4838. The drawing represents one-half of the tumor, which was 
attached to the enlarged fundus by the very short broad-based i^edicle situated in the vicinity of 
d. The tumor is roughly divided into a semi-solid and a cystic portion. The cyst is irregular in out- 
line and, as seen in Fig. 38, at a it connects with little bays extending oflf into the solid portion. 
In some places the cyst wall is very thin, as at a. The ragged appearance in the interior of the cyst 
and the smooth homogeneous substance just within the cyst wall are due to coagulated cyst con- 
tents. The inner surface of the cyst is in reality smooth and velvety. The solid portion of the 
tumor is composed of a diffuse myoma. Scattered throughout it are large and small cyst-like 
spaces, b is such a cavity. It is, however, irregular in form and branches out considerably. It 
has a smooth inner lining. In the space c the coagulated contents still remain. There are also 
numerous smaller spaces scattered throughout the myomatous tissue. These spaces, on careful 
study, do not convey the idea of cysts, but it seems as though the muscle were being tunnelled in 
various directions by spaces of variable size. For the very low magnification see Fig. 38. 

Sections from the large subperitoneal myoma show a ver}^ in- 
teresting picture. This nodule consists essentially of myomatous 
tissue, but here and there bundles of normal muscle still remain 
(Fig. 38). The small cyst-like spaces noted in the solid portion of 
the tumor have an inner lining of a single laj^er of cylindrical and 



SUBPERITONEAL AND INTRALIGAMENTARY ADENOMYOMATA 131 

apparently ciliated epithelium. This is in most places separated 
from the surrounding myomatous tissue by a stroma somewhat 
resembling that of the uterine mucosa; and scattered throughout 
the stroma are occasional small glands identical with those of the 
uterine mucosa. At some points in these cysts the epithelial lining 




Fig. 38. — A cystic subperitoneal adenomyoma of the uterus. (1^ natural size.) 

Gyn.-Path. No. 4838. The section is through the same tumor as Fig. 37, but at 
another level. A is the same large cyst cavity. It has a small bay (a) extending off to the left. 
It is lined with a single layer of epithelium, which from the text is seen to be cylindrical. Just 
beneath the epithelial lining at 6 is a small gland; c represents the coagulated cyst contents. B 
and C are irregular cyst-like spaces lined with one layer of epithelium. In the neighborhood of d 
are numerous small glands, also lined with cylindrical epithelium. Some of the glands, notably at e, 
are surrounded by a definite circular zone of myomatous muscle. The deeply staining areas, as 
seen at e', are the myomatous muscle bundles. The intervening pale framework is a somewhat 
rarefied connective tissue. We should not be much surprised if at one time all the large cyst 
cavities communicated with one another. 



has disappeared and the underlying tissue shows distinct evidences 
of old hemorrhage. These cyst-like spaces contain a variable quan- 
tity of blood. Scattered throughout the solid portion of this sub- 
peritoneal nodule are numerous smaller cysts varying from 1 to 3 
mm. in diameter. These are lined with one layer of cylindrical epithe- 



132 ADENOMYOMA OF THE UTERUS 

Hum and are separated from the muscle by a definite stroma. They 
contain a good deal of blood. One of these cysts may be roughly 
likened to a cross-section of a miniature uterine cavity, as it is 
partially surrounded by glands similar to those of the uterine mucosa. 
Scattered here and there throughout the myoma are similar glands, 
the majority lying in direct contact with the uterine muscle and not 
being surrounded by stroma. It is particularly interesting to note 
that the myomatous tissue is most dense immediately around the 
cyst-like spaces. The large cystic portion of the subperitoneal 
myoma consists essentially of one cavity. Near the solid portion, 
where there has not been much opportunity for stretching, this 
cyst is lined with one layer of fairly well preserved cylindrical and 
apparently ciliated epithelium. Sometimes this epithelium rests 
directly on the muscle, but in many places is separated from it by 
stroma similar to that of the mucosa; in this stroma the blood- 
vessels are often greatly dilated. As we gradually approach the 
more prominent portion of the cyst, where the walls are ver}^ thin, 
the epithelial lining becomes thinner and thinner and entirely dis- 
appears. Clinging to the inner surface here is fibrin, holding in its 
meshes a variable quantity of blood. As is clearly evident from the 
description, this is a subperitoneal adenomyoma which has become 
cystic. Although we have cut many sections, it has been impossible 
to trace a direct connection between the uterine mucosa and the glands 
of the subperitoneal adenomyoma. Nevertheless, we have seen that 
the uterus shows a diffuse myomatous transformation and that the 
uterine glands, at one point at least, are commencing to extend into 
the depth. 

Diagnosis . — Diffuse myomatous thickening of the uterine 
walls; interstitial and subperitoneal myomata; slight edema of 
the uterine mucosa with commencing extension of the glands into 
the depth; subperitoneal cystic adenomyoma. 

Gyn. No. 3293. Path. No. 583. 
Subperitoneal, interstitial, and sub- 
mucous myomata. Multiple cysts in a sub- 



SUBPERITONEAL AND INTRALIGAMENTARY ADENOMYOMATA 133 

peritoneal mj^oma (Figs. 39 and 40) . Atrophy and 
edema of the uterine mucosa. Double peri- 
salpingitis and perioophoritis. Hysterec- 
tomy. Recovery. 

P. S., single, aged forty, colored. Admitted January 23, 1895; 
discharged February 24, 1895. One child, twenty years ago; no 
miscarriages. The menses appeared at fifteen; they were regular 
but painful. Since the onset of the present trouble they have been 
much more profuse, lasting three days and accompanied by intense 
pain. The patient has had a thin bloody, offensive, leucorrhoeal 
discharge, containing shreds for two weeks after each menstrual 
period, then giving place to a white, offensive discharge lasting until 
the next period. 

Ten years ago she noticed a small lump in the abdomen, more 
prominent during menstruation. The tumor has grown steadily 
and now practically fills up the abdomen; there has been some 
dull pain over the region of the mass (following an accidental blow 
thereon), the pain being more severe at menstrual periods. 

Examination . — The abdomen is much distended by a hard, 
sensitive, irregular mass. The cervix is pushed against the sym- 
physis; the whole vaginal vault is filled with a hard immovable 
mass. 

Operation. January 30, 1895. Panhystero-myomectomy. 
General peritoneal adhesions, three large subserous myomata ; sub- 
mucous myoma ; involvement of posterior lip of cervix necessitating 
panhysterectomy. Recovery. 

Gyn.-Path. No. 583 . — The specimen consists of a 
large irregularly shaped uterus, with tumors springing from both 
sides. The portion of the uterus present is approximately 14 cm. 
long, 14 cm. broad, and 15 cm. in its antero-posterior diameter. 
The anterior surface is roughened and anteriorly and posteriorly 
it is covered with many dense adhesions. Springing from the an- 
terior and posterior surfaces are somewhat flattened nodules, vary- 
ing from 1 to 4 cm. in diameter. The under cut surface of the 
uterus is 9 cm. in diameter and the cervical canal, which is completely 



134 



ADENOMYOMA OF THE UTERUS 



blocked by a reddish injected mass, is 5.5 cm. from side to side. The 
uterine walls average 3 cm. in thickness. Their muscle fibres are 




R.Tube 



Cer\Aical' Carnal ^ ^'"^ 



Fig. 39. — A subperitoneal cystic adenomyoma occurring in the case of a large myo- 
matous UTERUS, (i natural size.) 

Gyn.-Path. No. 583. The uterus is much enlarged, owing to the presence of myo- 
matous tumors. Projecting through the cervix is a small portion of a submucous myoma and 
situated anteriorly and to the left are the large myomata a and b, only dimlj'^ outlined. The right 
tube, although lengthened, is little altered. It is attached to the ovary by a few bands. Scattered 
over the posterior surface of the uterus are several sessile nodules and one of moderate size with 
several cysts springing from its surface, c is a single cyst and at d a group of seven are seen. All 
are thin-walled and semi-translucent. As learned from the text, they are not subperitoneal cysts, 
their walls being composed of myomatous tissue, and furthermore they are lined with a single layer 
of cylindrical epithelium. For the histological picture see Fig. 40, which is taken from the area d. 



SUBPERITONEAL AND INTRALIGAMENTARY ADENOMYOMATA 135 

much coarser than usual, and scattered here and there throughout 
the walls are whitish nodules varying from .5 to 2.5 cm. in diameter. 
The portion of the uterine cavity present is 12 cm. in length, and 
springing into it are several nodules, the largest reaching 2.5 cm. in 
diameter. The uterine mucosa is pinkish-white in color and averages 
1.5 mm. in thickness. Over the large nodule it is somewhat atrophic. 
Projecting into the cavity from the left side is an irregular, globular, 
pear-shaped mass measuring 16 by 10 by 10 cm. It is the lower 
portion of this that projects through the cervix. This nodule pres- 
ents depressions corresponding to the small submucous nodules. 
It is covered with mucosa which is apparently very edematous. 
The mucosa averages 1 mm. in thickness, but where edematous is 
fully 4 or 5 mm. thick. Springing from the right side of the uterus 
is a nodule, 6 by 5.5 by 5 cm. This is covered with adhesions, and 
has springing from it numerous subperitoneal cysts forming a mass 
fully 5 cm. in size. The tumor is soft and boggy. Projecting from 
the left side of the body of the uterus are two kidney-shaped masses. 
The larger measures 22 by 13 by 11 cm., is pinkish in color, slightly 
lobulated, and is covered with numerous adhesions binding it to the 
uterus and the adjoining tumor. The adhesions are very vascular. 
The smaller tumor measures 12 by 7 by 8 cm. and closely resembles 
its neighbor. The uterine tumors on section are pinkish-white in 
color and for the most part consist of fibres, having a concentric 
arrangement. The large tumor to the right of the uterus contains 
areas, fully 2.5 cm. in diameter, consisting of a fine network of fibres 
traversing a cavity filled with clear transparent fluid. Numerous 
smaller but similar areas are scattered throughout the tumor. They 
are undoubtedly areas of degeneration. The small kidney-shaped 
nodule springing from the fundus presents numerous small, yellow- 
ish-white, granular areas — foci of calcification. The small and soft 
nodule to the right of the uterus shows some degeneration. This 
nodule on section is found to be partially cystic over an area 5.5 cm. 
(Fig. 39). These cysts in the hardened specimen vary from the 
size of a pea to 3.5 cm. in diameter; they have exceedingly thin walls, 
smooth inner surfaces, and at once suggest a multilocular ovarian 



136 



ADENOMYOMA OF THE UTERUS 



cyst. There are numerous similar areas scattered throughout the 
tumor. There is absolutely no connection between the ovary and 
this tumor, as the latter is situated 8 cm. from the ovary. 

The tubes and ovaries are enveloped in dense adhesions. 

Histological Examination . — The uterine mucosa 
is much atrophied, but near the fundus, where it is somewhat pro- 
tected, it reaches 3 mm. in thickness. The surface presents an intact 
epithelium. The glands are in places abundant, in other parts 




Fig. 40. — Cystic subperitoneal adenomyoma of the uterus. (6 diameters.) 

Gyn.-Path. No. 583. The section is from point d, Fig. 39. a is the sohd myoma- 
tous portion of the tumor; b is the thin myomatous layer forming the outer walls of the cysts c and 
d. The outer peritoneal covering is represented by h' . The cyst spaces, c and d. have convoluted 
inner surfaces and at many points (e) there are gland-like depressions. The cysts and also the 
depressions are lined with a single layer of cylindrical ciliated epithelium. Situated in the myo- 
matous tissue at / and / are two gland-like spaces which bear a most striking resemblance to hyper- 
trophic uterine glands, g is the edge of a neighboring cyst. 



scanty. Some are small and round on cross-section, others are 
slightly dilated, but all have an intact epithelium. The stroma of 
the mucosa is of a moderate density and is composed of cells having 
oval or elongate-oval nuclei. Over the small submucous nodule at 
the fundus the mucosa has almost entirely disappeared. The surface 
is here covered with epithelium which in some places is cylindrical, 
in other places almost flat, while at some points it is two or three 
layers in thickness, is swollen, and resembles squamous epithelium. 
Beneath the surface epithelium are a few stroma cells and beneath 



SUBPERITONEAL AND INTRALIGAMENTARY ADENOMYOMATA 137 

these are numerous small round cells. The glands at this point have 
entirely disappeared. The mucosa over the large submucous nodule 
in the most prominent portions is represented by one layer of epithe- 
lium, which is poorly defined, being almost flat. Beneath this is 
a small amount of stroma, but all of the glands have disappeared. 
Where the mucosa looked edematous the epithelium covering the 
surface is intact, but rests directly on the muscle, there being no 
intervening stroma. The muscle has undergone partial or complete 
hyaline degeneration and has in many places practically disappeared, 
leaving a colorless tissue, scattered throughout which are a few small 
round cells, red blood-corpuscles, and polymorphonuclear leucocytes. 
The portions that have not yet broken down show numerous cells 
which have taken up golden-yellow pigment. Taken as a whole, 
the mucosa, where present, is normal, but where subjected to pressure 
has undergone partial or almost complete atrophy. In some places 
it shows considerable edema. 

The nodules scattered throughout the uterus or situated on its 
outer surface are composed of non-striped muscle fibres which have 
been cut in various directions. They all show a moderate amount 
of localized or diffuse hyaline degeneration. 

The cystic portion of the nodule situated to the right of the uterus 
presents a very unusual picture. The cyst walls are composed of 
tissue that cannot be distinguished from the muscle fibres of the 
part and the cyst cavities are lined with a single layer of cylindrical 
epithelium (Fig. 40). The nuclei of the epithelial cells are oval or 
almost round and are situated near the centres of the cells. These 
cells are ciliated and closely resemble the epithelium covering the 
surface of the uterine mucosa. In some places the walls of the cavity 
are gathered up into little papillary -like folds; in other places ir- 
regular, convoluted, gland-like cavities are found scattered through- 
out the walls. These are very strongly suggestive of gland hyper- 
trophy as seen in the uterine mucosa. In a few places the walls of 
these cysts show evidence of hemorrhage, their cells having taken 
up large quantities of fine yellow granular pigment. These glands 
and cysts occurring in the myoma are evidently due to embrj^onic 



138 ADENOMYOMA OF THE UTERUS 

displacements. I am inclined to think that they have been derived 
from Miiller's duct: (1) because the epithelium bears such a striking 
likeness to that of the uterine mucosa; and (2) because of the pig- 
ment in the cyst wall. If these cysts are derivatives of Miiller's 
duct, we should naturally expect them to take part in the menstrual 
flow. The blood resulting cannot escape and must needs be taken 
up by the cyst walls. This will account for the pigment. The ap- 
pendages are covered with numerous adhesions, but are otherwise 
normal. 

Diagnosis . — Subperitoneal, interstitial, and submucous 
myomata. Multiple cysts in a subperitoneal myoma, these cysts 
probably being due to remains of Miiller's duct. Atrophy and 
edema of the uterine mucosa. Double perisalpingitis and peri- 
oophoritis. 

Gyn. No. 9024. Path. No. 5187. 

Subperitoneal and partly interstitial ade- 
nomyoma removed by excision through the 
abdomen. 

L. C, married, aged thirty-eight. Admitted August 30, 1901; 
discharged September 2, 1901. The patient entered complaining 
of constant uterine hemorrhage. Her periods have never been 
regular. Since she had typhoid when twenty years of age, the 
duration of the flow has been increased and the intervals have been 
gradually growing shorter. In July of this year (1901) she was ad- 
mitted to the hospital, and previous to this had had constant bleed- 
ing for nine weeks, with considerable dysmenorrhoea. Shortly after 
admission to the hospital she was curetted. Three weeks after 
leaving the hospital she had another period, and bleeding has con- 
tinued ever since, becoming more and more profuse and occasionally 
being clotted. The patient has pain in her back and lower abdomen. 

Operation . — Abdominal mj^omectomy, hysterotomy, curet- 
tage and suspension of the uterus. Two small nodules were 
found in the posterior surface of the uterus. These were removed. 
The uterus was then split, the cavity exposed, and the mucous mem- 



SUBPERITONEAL AND INTRALIGAMENTARY ADENOMYOMATA 139 

brane found to be apparently normal. The cervix was dilated from 
above. The uterus was then suspended in the usual way. The 
patient made a satisfactory^ recovery. 

Path. No. 5187 . — The specimen consists of a small amount 
of curettings and of a piece of tissue 1.8 cm. in diameter. The surface 
of this tissue presents a smooth peritoneal covering. Beneath this 
is a dense nodular myoma, 5 mm. in diameter. In the centre of 
this nodule is a cavity, 2 by 1 mm., lined with a very thin smooth 
membrane. Sections show the tumor to be a typical myomatous 
growth, and scattered throughout it are several cysts lined with a 
definite mucosa. The epithelium lining the cavity is of the cy- 
lindrical variety. The underlying stroma is similar to that of 
the uterine mucosa. The growth is a typical adenomyoma. Of 
course, it is impossible for us to trace any relationship with the uter- 
ine mucosa, as the uterus was not removed. 

Gyn. No. 9637. Path. No. 5840. 

Adenomyoma apparentl}'' subperitoneal; 
removed through the abdomen. 

I. D., colored, married, aged nineteen. Complaint: Cramps in 
the lower left side of the abdomen. Her menses were normal up to 
a 3^ear ago. Since then there has been cramp-like pain in the lower 
abdomen. She has had one child and one miscarriage. Her periods 
now last longer than formerly. 

Operation : Abdominal myomectomy. The patient made 
a satisfactory recover}^ and was discharged on the twentieth day. 

Path. No. 5840 . — The specimen consists of a mutilated 
myoma which is oval in shape and approximately 2.5 cm. in diameter. 

On histological examination this presents the 
typical myomatous appearance, and scattered throughout it are 
areas which resemble uterine mucosa. It is a clear case of 
adenomyoma, apparently subperitoneal. 

Diagnosis . — Adenomyoma, apparently subperitoneal. 



140 ADENOMYOMA OF THE UTERUS 

Gyn. No. 12,585. Path. No. 9336. 

Gland hypertrophy. Small uterine myo- 
mata. Adenomyoma, apparentl}^ subperito- 
neal, 4 mm. in diameter. 

K. H., married, aged thirty-five, white. Admitted December 28, 
1905; discharged January 17, 1906. Complaint: Pain in the lower 
abdomen; a leucorrhoeal discharge and a bearing-down sensation 
in the pelvis. The menses began at twelve and were regular every 
twentj^-eight daj^s. The flow was rather scanty and occasionally 
clotted. The last period occurred three weeks ago. The patient 
has been married four 3^ears but has had no children. She is some- 
what emaciated ; the mucous membranes are rather pale. 

Operation : Dilatation and curettage. Abdominal my- 
omectom}^ resection of right ovary. Several small myomata were 
removed from the uterus. The patient made a very satisfactory 
recovery. The highest post-operative temperature was 100° F. 

Path. No. 9336 . — The specimen consists of a moderate 
amount of curettings and of two nodules from the right ovary and 
two myomata from the uterus. 

On histological examination we find gland hyper- 
trophy, a corpus luteum, and two small myomata. One myoma 
presents the usual appearance and shows hyaline transformation. 
A note was made that macroscopically one of these small nodules 
from the uterus looked like a little black vesicle and somewhat 
resembled a thrombosed vein. It is a myoma containing small 
cystic spaces. The c^^stic spaces are lined with one layer of epithe- 
lium and are filled with blood. In the immediate vicinity are 
several small gland-like spaces and some stroma. The growth is a 
typical adenomyoma. It is not over 4 mm. in diameter. 

Diagnosis . — Gland hypertrophy ; discrete uterine myo- 
mata and discrete adenomyoma. 

H. A. K. Sanitarium No. 1872. Path. No. 8433. 
Uterine myomata, subperitoneal and in- 
terstitial nodules, adenomyoma of the uter- 



SUBPERITONEAL AND INTRALIGAMENTARY ADENOMYOMATA 141 

ine walls; discrete adenomyoma of the utero- 
ovarian ligament, showing large islands of 
mucosa, typical miniature uterine cavities 
(Figs. 41 and 42). 

D., white, married, aged fifty-one. Admitted March 22, 1905. 
Died April 15, 1905. Patient has always been a frail woman. Since 
the menopause there has been a slight vaginal discharge. She has 
been aware of the presence of an abdominal tumor for the past six 
months. There has been a great deal of pain and a feeling of weight 
in the abdomen. She apparently had an attack of pelvic peritonitis 
in January. Her haemoglobin is 50 per cent. 

Operation . — Hystero-myomectomy, repair of the perineum. 
The patient after operation was exceedingly nervous and had a great 
deal of pain. On the fourth day she was as bright as usual, when 
she suddenly began to scream and became unconscious and died in 
a very short time. Embolism was thought to have been the cause 
of death. Her highest post-operative temperature was 100° F. 

Path. No. 8433 . — The specimen consists of a multi- 
nodular myomatous uterus which has been amputated through the 
cervix. It is 14 cm. in length, 13 cm. from side to side, and perfectly 
smooth. The nodules seen on the outer surface vary from 2 to 9 cm. 
in diameter. The right tube and ovary are normal. The left tube 
presents the usual appearance. The left ovarj^ contains what ap- 
pears to be a corpus-luteum cyst, 3 cm. in diameter, at its outer pole. 
Perfectly independent from the uterus and attached to the utero- 
ovarian ligament on the left side is a myoma, 6 cm. in length, 4 cm. 
in breadth, and 3 cm. in thickness (Fig. 41). Projecting slightly 
from the surface are a subperitoneal cyst, 1 cm. in diameter, and 
numerous smaller ones. 

On making sections of the nodule projecting from the left utero- 
ovarian ligament we find in the lower part cystic spaces reaching 
1.5 cm. in diameter. Sections through the middle portion show 
cystic spaces 1 mm., others 2 mm., and some 4 mm. in diameter. 
Section through the attachment of the myoma to the utero-ovarian 
ligament reveals a cystic space, 7 mm. in length and approximately 



142 



ADENOMYOMA OF THE UTERUS 



3 mm. broad. It has a definite yellowish lining and encloses choco- 
late-colored contents. Several of the spaces are filled with a brown- 




FiG. 41.— Subperitoneal and interstitial uterine myomata; adenomyoma of the body 

OF THE UTERUS. AdENOMYOMA SPRINGING FROM THE LEFT UTERO-OVARIAN LIGAMENT. 

(^ natural size.) 

Gyn.-Path. No. 8433. The uterus is the seat of subperitoneal and interstitial 
myomata. Near the cervix on the anterior surface is a small cyst. The left tube is normal. The 
left ovary contains a small corpus-luteum cyst, b. Projecting from the left utero-ovarian ligament 
is a subperitoneal myoma, a. This has a few cysts projecting from its surface as indicated. On 
section this nodule was found to contain cysts, 1 cm. or more in diameter, lined with mucosa and 
filled with chocolate-colored blood, miniature uterine cavities, also whitish yellow areas, and 
normal uterine mucosa. (See Fig. 42.) 

It may be of interest to know that the uterine mucosa extended into the myomatous uterine 
walls. 

ish putty-like material and have yellowish margins. The ovary 
contains a cystadenoma. 

On section the uterine cavity is 7 cm. in length and the mucosa 



SUBPERITONEAL AND INTRALIGAMENTARY ADENOMYOMATA 143 

in places reaches 9 mm. in thickness. Some of the glands are dilated. 
The muscular layers of the uterus present a rather coarse, striated 
appearance. 

On histological examination the cervical mucosa 
is perfectly normal in many places; at other points, however, there 
is a great deal of gland dilatation, and there is a large thin-walled cyst 
lined with one layer of flat epithelium and filled with coagulated ma- 
terial presenting a picture almost identical with one of the thyroid. 
This appearance is due to massive dilatation of some of the cervical 
glands. We also have small cysts presenting a sieve-like appearance. 
This picture is due to a polypoid formation at certain points. The 
uterine mucosa in places reaches 11 mm. in thickness. In many 
places it has been most imperfectly preserved. The surface, how- 
ever, is practically intact. The glands are ribbon-like owing to 
degeneration, and we are unable to tell why the mucosa was so 
thickened, on account of this degeneration. There is, however, not 
the slightest evidence of any malignancy. The underlying muscle 
is somewhat dense, and in it near the mucosa we find isolated glands 
which have extended down from the surface. In one of the sections 
an island of mucosa with the characteristic stroma surrounding it 
can be seen at least 3 mm. from the mucosa. The growth is 
a definite adenomyoma, with the glands com- 
ing from the mucosa. Sections from the nodule spring- 
ing from the left utero-ovarian ligament show a most instructive 
picture (Fig. 42). A transverse section over the point of attach- 
ment of the utero-ovarian ligament, where we noticed several spaces, 
shows that these are lined with one layer of cylindrical epithelium. 
This at times projects out as little tufts and beneath it, and sepa- 
rating it from the muscle, is a certain amount of characteristic 
stroma. In other portions of this nodule we have little gland-like 
spaces extending out into this main cavity. Still other sections 
contain glands resembling uterine glands in every way. These are 
separated from the muscle by a characteristic stroma. Sections 
from the centre of the nodule show a most interesting picture. 
We have cyst-like spaces similar to those above described, and 



144 



ADENOMYOMA OF THE UTERUS 



likewise miniature uterine cavities. Some of the glands are 
dilated. In the vicinity is a group of glands similar in 
appearance. We have here subperitoneal and interstitial uterine 
myomata ; marked thickening of the endometrium with definite ade- 
nomyomatous formation, and adenomj^oma of the left utero-ovarian 
ligament. This myoma is diffuse in character, contains cyst-like 



"T)^' 








o. -b 



^ 



Fig. 42. — Cross-section through a pedunculated subperitoneal adenomyoma. (4 diam- 
eters.) 

Gyn.-Path. No. 8433. The picture represents a cross-section through the subperitoneal 
adenomyoma a in figure 41. Scattered throughout the tissue are isolated cystic and dilated 
glands (a). Near the centre are two large areas of typical uterine mucosa ; one of these contains a 
miniature uterine cavity as indicated at b. The darker tissue as seen at c indicates the myomatous 
muscle. This stands out in sharp contrast to the paler staining stroma as indicated at d. 



spaces and miniature uterine cavities. In other areas it is a typical 
adenomyoma, differing in no way from an adenomyoma with the 
glands originating from the mucosa. The mucosa in this case shows 
a definite adenomyomatous tendency as it extends into the under- 
Ij^ing muscle. It seems reasonably probable that the adenomyoma 
of the utero-ovarian ligament at one time lay next to the uterine 
mucosa, and that it was gradually pushed outward until it became 



SUBPERITONEAL AND INTRALIGAMENTARY ADENOMYOMATA 145 

subperitoneal and to all intent and purpose lost its continuity with 
the uterus. 

Gyn. No. 12,036. Path. No. 8579. 

Subperitoneal and interstitial uterine 
myomata, one of which was an adenomyoma. 

M. Y., aged forty-six, white, married. Admitted April 8, 1905; 
discharged May 22, 1905. Complaint: Right inguinal hernia; 
descensus and retroposition of the myomatous uterus, ulceration of 
the vagina. One aunt has cancer. The menses commenced at 
eighteen. The menopause occurred in November, 1904. The 
patient has been married fourteen years and has never been pregnant. 
The inguinal hernia was noticed two years ago. In the posterior 
vaginal wall there is a granulating area about 8 mm. in diameter 
just two inches from the outlet. 

On opening the abdomen a small flat myoma was found in the 
posterior wall near the cervix. This was removed, and some small 
interstitial nodules were shelled out. The hernia was repaired and 
the patient made a good recovery. The highest post-operative 
temperature was 99° F. 

Path. No. 85 7 9 . — The larger specimen consists of a 
myoma, 4 by 2 by 2 cm. This is partly subperitoneal. There are 
also small interstitial nodules. On section numerous cyst-like 
spaces are to be made out in the myoma, which presents a coarse 
striation and suggests adenomyoma. Throughout this myoma 
definite spaces can be seen. These are lined with a single layer of 
columnar epithelium. At one or two points the glands can be traced 
for a distance of 5 mm. As the uterine cavity was not opened, of 
course it is impossible for us to trace the continuity with the mucosa. 

Diagnosis . — Subperitoneal adenomyoma; small inter- 
stitial nodules. 

INTRALIGAMENTARY ADENOMYOMATA 

Case 8780 is a very good example of this variety, although the 

growth also projects into the uterine cavity. As seen in Fig. 43, 
10 



146 ADENOMYOMA OF THE UTERUS 

it is a goodly sized tumor which extends far out into the right broad 
Hgament, the folds of which it widely separates. Where it becomes 
submucous, its character is more evident. It is covered over with 
mucosa, but presents a rather lobulated appearance owing to the 
presence of cysts of varying size projecting inward from the growth. 
From the soft character of the growth sarcoma was suspected at the 
time of operation, particularly as the mucosa was intact and showed 
no evidence of a carcinomatous process. Fig. 44 is a cross-section 
of the opened uterus, taken near the fundus. The growth is seen to 
be a myoma covered externally with a layer of normal muscle and 
internally with mucosa. Traversing it everj^where are large and 
small irregular cyst cavities. On histological examination some of 
these cavities were found to communicate with one another. They 
were in part empty, in part filled with coagulated serum or blood. 
They had a smooth inner lining resembling mucosa. This in places 
was of appreciable thickness. The microscopic examination re- 
vealed the fact that some of them resembled miniature uterine cavi- 
ties, having an inner lining of cylindrical epithelium beneath which 
were typical uterine glands embedded in their usual stroma. At c 
in Fig. 45 we even noted hypertrophy of some of the glands so char- 
acteristic of the uterine mucosa in some cases. Others of the cysts 
had no glands, merely a row of cylindrical cells separating them 
from the myomatous muscle. The uterine mucosa was normal and 
no connection was found between the adenomyoma and the mucosa 
lining the uterine cavity. 

Kroenig^ reports a very interesting instance of a cystic adeno- 
myoma springing from the posterior wall of the uterus and extend- 
ing backward beneath the peritoneum of Douglas' pouch. It con- 
sisted of one large, thin-walled cyst containing a litre of brownish- 
red fluid, and of a more solid portion consisting of about thirty small 
spaces so arranged that they resembled a honeycomb. The walls 
of the large cyst, especially of that portion lying free in the abdominal 

^ Kroenig, B. : Ein retroperitoneal gelegenes voluminoses Polycystom entstanden 
aus Resten des Wolff 'schen Korpers. Beitrage zur Geburtshiilfe und Gynak., 1901, 
Bd. iv, p. 61. 



SUBPERITONEAL AND INTRALIGAMENTARY ADENOMYOMATA 147 

cavity, were very thin, in places measuring scarcely more than 1 mm. 
The cyst walls were composed of fibrous tissue and of a varying 
amount of muscle. The inner surface was in places lined with cylin- 
drical ciliated epithelium. The more solid portion of the tumor was 
a typical cystic adenomyoma which, as Kroenig says, in form, in ar- 
rangement of glands and in the cystic spaces, corresponded in prac- 
tically all points with the adenomj^omata of von Recklinghausen. 
There were definite groups of glands surrounded by the characteristic 
stroma. Kroenig thinks that the tumor originated in the uterine 
wall, and was later pushed out into the connective tissue of Douglas' 
pouch. 

Hartz^ observed a similar case in Sanger's clinic. 

While considering intraligamentary adenomyomata we must not 
omit the two interesting cases reported by Breus- in 1894. In his 
Case 1 a large, partly cystic and partly solid myoma was met with in 
the right broad ligament. On removal it was found to be made up 
of a framework of myomatous tissue containing several large cysts. 
Their dimensions may be imagined from the fact that 7 litres of 
thick grayish-brown fluid were evacuated prior to the removal of 
the tumor. The cyst cavities had smooth inner surfaces and ap- 
peared to be lined with mucous membrane. In the more solid por- 
tions, definite myomatous nodules as large as a fist were found. 
Such nodules on section contained large, smooth-walled cavities, 
which were filled with either light or dark brown, friable or thick, 
fluid contents similar to those of the large cyst. The tumor proved 
to be a typical myoma. The large cyst was lined with a single layer 
of cylindrical ciliated epithelium. Breus thought that the tumor 
was of uterine origin and that it had spread out between the folds of 
the broad ligament. 

Breus' Case 2 is even more instructive than the first. The patient 
was fifty-one years of age. There was a tumor the size of a child's 

^ Hartz, A. : Neuere Arbeiten iiber die mesonephrischen Geschwiilste. Monats- 
sehrift f. Geburtshiilfe und Gynakologie, Bd. xiii. 

^ Breus, Carl : Ueber wahre epithelfiihrende Cystenbildung in Uterusmyomen. 
Leipzig, 1894. 



148 ADENOMYOMA OF THE UTERUS 

head springing from the posterior surface of the uterus and covered 
by the peritoneum of Douglas' sac and the left broad ligament. The 
tumor on its upper and posterior surface was hard. On section it 
was seen to be composed of myomatous tissue, but the central portion 
contained several cavities. These varied from a pea to an apple in 
size and were in part separated from one another by thick partitions. 
Several of them, however, communicated one with the other. The 
cysts had smooth inner surfaces and were filled with a thick, choco- 
late-brown fluid. The largest cyst communicated directly with the 
uterine cavity by a funnel-shaped opening just above the internal 
OS. The cysts were lined with cylindrical, ciliated epithelium, and 
where the large cyst communicated with the uterine cavity the sur- 
face epithelium of the uterine mucosa was directly continuous with 
that of the cyst. Breus considered the tumor as a subperitoneal 
and intraligamentary cystic myoma of the uterus. 

The intraligamentary cystic adenomj^omata differ in no way 
from the subperitoneal growths except for the fact that they spread 
out between the folds of the broad ligament, and hence offer greater 
difficulty in removal. All of the tumors consist of myomatous tissue 
and contain characteristic glands and stroma, and furthermore all 
the cysts are lined with cylindrical and usually ciliated epithelium. 
Particularly instructive is Breus' second case, in which the epithe- 
lium of the uterine mucosa was directly continuous with that of the 
large cyst. Nearly all of the intraligamentary cysts are also par- 
tially filled with blood. 

It will be noted from the foregoing cases that wherever the 
subperitoneal or intraligamentary adenomyomata reach any size 
they become cystic. In some the cysts were single, but they were 
usually multiple. The cj^st walls were made up of myomatous 
tissue and their inner surfaces were lined with cylindrical epithelium, 
on which the cilia were usually demonstrable. The cysts almost 
without exception contained a chocolate-colored or bloody fluid. 
In the solid portion of the tumor tubular glands were found, sur- 
rounded by a definite stroma; in short, a definite mucosa, identical 
with that normally found lining the uterine cavity, was present. 



SUBPERITONEAL AND INTRALIGAMENTARY ADENOMYOMATA 149 

Subperitoneal adenomyomata differ in no way from the diffuse 
uterine myoma ta save for the fact that they become cystic; and 
this difference is easily explained inasmuch as the subperitoneal 
tumors are released from the contracting and controlling influence 
of the uterine muscle. Their glands are occluded, and from the con- 
stant accumulation of the epithelial secretion and the frequent 
hemorrhages, which undoubtedly occur at the menstrual period, 
rapidly become larger. It will be noted that the large cysts are 
invariably found where the least amount of muscle is present. 

AN INTRALIGAMENTARY ADENOMYOMA OF THE UTERUS 

Gyn. Nos. 6855 and 8780. Path. No. 4966. 

Intraligamentary adenomyoma of the 
uterus extending into the right broad lig- 
ament and also becoming submucous (Figs. 43, 
44, and 45) . Gland hypertrophy of the uterine 
mucosa, slight pelvic adhesions. Hysterec- 
tomy. Recovery. (See page 160, for first operation.) 

A. B. W., aged thirty-six, white, married. Admitted May 21; 
discharged June 11, 1901. Complaint: Continuous bleeding from 
the uterus and pain in the right lower abdomen. The patient has 
been married sixteen years and has had three children. The menses 
commenced at twelve, and were regular, lasting about four days. 
There was no pain and the flow was moderate. 

On April 22, 1899, a vaginal myomectomy was done, a sub- 
mucous adenomyoma being removed. Before this operation there 
had been a slight bloody discharge at irregular intervals. Menstrua- 
tion was normal after the operation until five years ago, when the 
patient began to have continuous profuse bleeding from the uterus 
and pain in the right side. She was curetted two or three times 
and the last two periods were normal. For the past two or three 
years leucorrhoea has been profuse. At times there has been 
dysuria, when the uterus seemed to press on the bladder. On 
such occasions it was necessary for her to push the uterus up 
before she could urinate. The bowels are constipated. 



150 ADENOMYOMA OF THE UTERUS 

The outlet is very much relaxed. The cervix is lacerated and 
the orifice is 2 cm. in diameter, slightly bluish. The uterus forms a 
mass filling two-thirds of the pelvis, the organ being about the size 
of that of a three and a half or four months' pregnancy. The uterine 
cavity is 13 cm. long and is displaced somewhat to the left. 

Operation, May 22, 1901. Panhysterectomy. Suspension 
of the corners of the vagina to the round, infundibulo-pelvic and 
sacro-uterine ligaments on either side. On opening the abdominal 
cavity the appearance strongly suggested a sarcoma involving the 
right uterine walls and extending into the right broad ligament. 
The right tube and ovary were adherent to the pelvic floor. The 
left tube and ovary were normal except for slight ovarian adhe- 
sions. 

Gyn.-Path. No. 4966 . — The specimen consists of an 
enlarged uterus with the tubes and ovaries intact. The uterus is 
somewhat pear-shaped and irregular in outline. It is 14 cm. in 
length, 13 cm. in breadth, and 12 cm. in its antero-posterior diameters. 
Anteriorly it is smooth and glistening; posteriorly, much injected 
and covered with a few recent adhesions. The increase in the size of 
the uterus is in great part due to a tumor occupying the right side of 
the body and extending out into the folds of the right broad liga- 
ment and also to the posterior and right side. This tumor is ap- 
proximately 10 cm. in diameter, is exceedingly soft, and feels like 
a cyst with the walls probably 5 mm. thick. On opening the uterus 
the external os is found to be 2.5 cm. in diameter; the mucosa of 
the vaginal portion is intact, but just beneath the mucous mem- 
brane are a few Nabothian follicles. The cervical canal is much 
dilated and is 3.5 cm. in length. Its mucosa is intact, but apparently 
somewhat thickened (Fig. 43). The cavity of the uterus is 8 cm. 
in length and averages 5 mm. in breadth in its middle portion. The 
uterine walls vary from 2 to 3 cm. in thickness. Projecting into 
the uterine cavity and apparently continuous with the mass on the 
right side is a somewhat globular tumor, 7 cm. in length and 6 cm. 
in breadth. This has a very broad basal attachment, presents a 
fairly lobulated surface, and is everywhere covered with mucosa. 



SUBPERITONEAL AND INTRALIGAMENTARY ADENOMYOMATA 151 




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152 



ADENOMYOMA OF THE UTERUS 



which, however, is somewhat thinned out. On pressure the sub- 
mucous tumor gives the impression of being cystic. The uterine 
mucosa averages 2 mm. in thickness, is smooth and grayish- white in 
appearance. 

Right side: The tube is 12 cm. in length and near the uterus 
averages 5 mm. in diameter; it is free from adhesions. The fim- 




FlG. 44. A CYSTIC INTRALIGAMENTAKV AM) I'AKTLV SUBMUCOUS ADENOMYOMA OF THE UTERUS. 

(Natural size.) 

Gyn.-Path. No. 4966. The drawing illustrates a section through Fig. 43 between 
b and b\ a is a cross-section of the left tube. 6 is a small portion of the uterine cavity, c is the 
submucous portion of the cystic adenomyoma and d its intraligamentary pole, e is one of the 
irregular cyst-like spaces with a smooth velvety inner lining resembling mucosa. Just above it is a 
similar but smaller one. The other spaces, as indicated by /, also irregular in outline, are filled 
with glistening coagulated contents which have not been removed. The coagulation, of course, 
was due to the hardening fluid, g is the characteristic myomatous tissue. The outline of the 
myomatous growth is well defined, but notwithstanding this fact the tumor merges gradually 
into the normal muscle. 



briated extremity is occhided and covered with adhesions. The tube 
in the vicinity of its outer end is 8 mm. in diameter and very firm. 
Situated just beneath the tube and within 3 cm. of its fimbriated end 
is a firm bean-shaped area 1.2 cm. in length. On section it is found 
to be a cyst-like space lined with smooth mucosa and filled with a 
brownish-yellow material, partly soft, but at one point evidently 
organized and adherent to the cyst wall. The ovarj^ measures 3 by 



SUBPERITONEAL AND INTRALIGAMENTARY ADENOMYOMATA 153 

2.5 by 1 cm. and is partially enveloped in adhesions and adherent 
to the tube. 

Left side : The tube is 1 1 cm. in length, and throughout its entire 
extent is very small, averaging not more than 3 or 4 mm. in diameter. 
The fimbriated extremity is patent, but the tube near its outer end 
is attached to the ovary by fan-like adhesions. The ovary measures 
4 by 3.5 by 2 cm. It contains a recent corpus luteum and apart 
from the tubal adhesions is free. 

On making a transverse section of the uterus after the specimen 
has been hardened in Miiller's fluid it is found that the tumor occupy- 
ing the right side and extending out into the right broad ligament 
is directly continuous with the submucous nodule which occupies 
the uterine cavity. In other words, we have an interstitial myoma, 
which on its inner side has become submucous and on its outer side 
extends into the broad ligament. This nodule is fully 8 cm. in 
diameter and is sharply differentiated from the uterine muscle, 
which on its outer side forms a covering 5 mm. in thickness. The 
myoma is irregular in contour and in places presents the usual pic- 
ture. It contains at least eight medium sized cyst-like spaces, the 
largest reaching 2.5 cm. in length and 1 cm. in breadth (Fig. 44). 
Each of these has a smooth lining membrane, waxy in appearance 
and varjdng from .5 to 1 mm. in thickness. The cavities of nearly 
all of these spaces are filled with a jelly-like material, evidently coag- 
ulated serum. One contains coagulated blood. The cyst-like spaces 
are more abundant in the central portions of the growth and toward 
the uterine cavity. They are similar to those noted beneath the 
surface of the submucous myoma. 

Histological Examination . — The mucosa lining 
the vaginal portion of the cervix and the cervical canal is normal. 
That covering the anterior portion of the uterine cavity is thickened ; 
the surface epithelium is somewhat flattened and its glands show 
marked hypertrophy. The stroma between the glands shows con- 
siderable small round-cell infiltration and is very lax. In the deeper 
portions it is unaltered. The mucosa covering the submucous 
portion of the tumor is somewhat thinned out. The surface epi- 



154 



ADENOMYOMA OF THE UTERUS 



thelium is intact, but the glands show sHght hypertrophy. One of 
the cysts, 1.5 cm. in length, .5 cm. in breadth, and situated directly 
beneath the mucosa, has a lining in no way distinguishable from 
uterine mucous membrane (Fig. 45). Its inner surface is covered 
with one layer of cylindrical and, in places, slightly flattened epithe- 
lium. Beneath this the characteristic stroma of the mucosa is 




Fig. 45. — The submucous portion of a cystic adenomyoma of the uterus. (5 diameters.) 

Gyn.-Path. No. 4966. The section is from the submucous myoma seen in Figs. 
43 and 44. a represents the uterine mucosa, which has an intact surface epithelium and per- 
fectly normal uterine glands. The stroma of the mucosa is rarefied but normal. A is one of the 
cyst-like spaces. At some points it is lined with a layer of cylindrical epithelium lying directly on 
the muscle. At other points this is separated from it by a small amount of stroma similar to that 
of the uterine mucosa. While in some places, as at 6, there are definite uterine glands beneath the 
epithelial lining, at c we have a uterine mucosa equally as thick as that covering the surface of the 
submucous myoma and consisting of a typical gland hypertrophy. B, C, D and E are other cyst- 
like spaces lined with cylindrical epithelium. A and B are evidently one and the same cavity, 
communicating as they do with one another by the bar d consisting of the characteristic stroma of 
the mucosa and containing two small glands. 

found, and scattered throughout the stroma are normal or hyper- 
trophied glands precisely similar to those noted in the mucosa 
lining the uterine cavity. Some of the cyst spaces, which are 
rather small, are lined with a layer of epithelium closely resembling 
that lining the uterine cavity. In a few places the nuclei of the 
epithelial cells are slightly drawn out and irregular. The myo- 
matous tissue as a whole presents the usual appearance. It has 



SUBPERITONEAL AND INTRALIGAMENTARY ADENOMYOMATA 155 

scattered throughout it, however, many small round cells, but prac- 
tically no polymorphonuclear leucocytes. The tubes and ovaries 
offer nothing of interest. 

We have, then, in this case a rather large and sharply defined 
myoma situated in the right uterine wall. This contains large and 
small irregular spaces lined with mucous membrane identical with that 
of the uterine mucosa. This myoma on its inner side has become 
submucous and its cyst-like spaces are seen projecting into the 
uterine cavity and lying just beneath the mucous membrane. 

Diagnosis : Adenomyoma of the uterus extending into 
the right broad ligament and also becoming submucous. Gland 
hypertrophy of the uterine mucosa, slight pelvic adhesions. 



CHAPTER VI 
SUBMUCOUS ADENOMYOMATA 

These are certainly not very common. We have aheady dis- 
cussed Case 8780 (Fig. 43, p. 151) under the heading of intraliga- 
mentary adenomyoma, but fully one-third of the growth is sub- 
mucous, projecting into and filling the uterine cavity from cervix 
to fundus. The surface is smooth but lobulated, on account of the 
underlying cysts which project toward the uterine cavity. As was 
said elsewhere, the growth was a typical adenomyoma and the cyst 
spaces were lined with cylindrical ciliated epithelium. Case 5973 
offers a very good illustration of a small submucous adenomyoma. 
The mucosa over the nodule has to a great extent disappeared, but 
here and there a gland is still visible. The growth is essentially a 
myoma. It contains three definite bunches of glands resembling 
uterine glands and surrounded by the typical stroma of the mucosa 
(Fig. 46). There are also a few isolated glands, some surrounded 
by stroma, others lying in direct contact with the muscle. Near 
the free surface is a cystic gland. In this case there were other 
myomata, necessitating the subsequent hysterectomy. 

In Case 6855 the submucous nodule contains a few small uterine 
glands. In Case 10,872 the myoma contains three cystic spaces, 
each 1 cm. in diameter and with a smooth lining, which on histo- 
logical examination is seen to consist of one layer of columnar epithe- 
lium. In Case 10,314 (Fig. 47, p. 162) we have a t3^pical example 
of a submucous myoma containing collapsed and dilated spaces 
lined with a definite mucosa. Some of these cavities are filled with 
chocolate-colored contents. 

On histological examination they are found to be miniature 
uterine cavities. In this case the uterine mucosa can be followed 
directly into the myoma. 

In 1896, when reporting two cases of diffuse adenomyoma of 

156 



SUBMUCOUS ADENOMYOMATA 157 

the uterus/ attention was directed to cases of submucous adeno- 
myomata reported by Diesterweg and Schatz.- In Diesterweg's 
case a nodule the size of a hen's egg presented at the external os. 
Its surface was somewhat eroded; it w^as attached above the in- 
ternal OS and projected downward by a pedicle an inch in thickness. 
The nodule was composed of myomatous tissue, and in the centre 
was a large cavity lined with mucosa and traversed by numerous 
small depressions, producing an appearance suggestive of a ventricle. 
There was a smaller cavity the size of a cherry. These cysts were 
lined with cylindrical ciliated epithelium and filled with brownish- 
black blood. Two years later, after the administration of ergotin, 
a submucous myoma, 9 by 7 by 6 cm., was expelled. This con- 
tained a cyst the size of a walnut. The cyst was lined with cylin- 
drical ciliated epithelium and filled with blood. 

In Schatz's case the uterus was 16 cm. long, 8.5 cm. in diameter, 
and its walls varied from 2 to 2.5 cm. in thickness. The uterine 
cavity contained five rows of broad-based polypi. Each row con- 
sisted of from two to six polypi. Between the rows were deep de- 
pressions. The polypi pointed toward the internal os and varied 
from a pea to a hen's egg in size. The uterine cavity was completely 
filled with them. On section the polypi were found to have a rich 
blood-supply and in several places bundles of muscle fibres could be 
seen extending into them and reaching almost to the free surface. 
Where the muscular elements predominated, the polypi were firm. 
Scattered throughout the uterine wall were small myomata which 
were not easily shelled out. In the myomata near the peritoneal 
surface no cysts were to be seen, but in those near the uterine cavity 
and also in the muscle they were present. The outer portions of 
the uterine wall were entirely free from cysts. The polypi consisted 

^ Cullen, Thomas 8.: Adenomyoma Uteri Diffusum Benignum. Johns Hopkins 
Hospital Reports, 1896, vol. vi. 

^ Diesterweg: Ein Fall von Cystofibroma uteri veriim. Zeitschr. f. Geb. u. Gyn., 
1883, Bd. ix, S. 191. Schatz: Ein Fall von Fibro-adenome cysticum diffusum et 
polyposum corporis et colli uteri. Arch. f. Gyn., 1884, Bd. xxii, S. 456. 



158 ADENOMYOMA OF THE UTERUS 

of spindle-shaped cells, and scattered throughout them were gland- 
like cavities lined with high cylindrical epithelium. 

It would appear that in these cases there had been a diffuse 
adenomyoma and that the uterus was trying to free itself of the new 
growth in the same manner in which it extrudes ordinary myomata. 
A polypoid condition had naturally resulted. 

Remembering the diffuse adenomyomata of the uterus and subse- 
quent extension of the growth to the outer surfaces, with the forma- 
tion of subperitoneal or intraligamentary cystic adenomyomata, it 
is easily understood that portions of the growth, at least, are forced 
inward and become submucous. In the submucous adenomyomata 
we do not generally expect much cystic dilatation of the glands, 
since the growth is continually subjected to the uterine pressure from 
all sides. 

CASES OF SUBMUCOUS ADENOMYOMA OF THE UTERUS 
Gyn. No. 5973. Path. No. 2250. 

Submucous adenomyoma of the uterus (Fig. 
46) . Removal per vaginam. Subsequent hys- 
terectomy on account of uterine myomata. 
Recovery. 

S. G., single, aged thirty-nine, black. Admitted March 22, 1898; 
discharged June 3, 1898. Complaint: continuous bloody vaginal 
discharge. The patient had one miscarriage twenty years ago. 
Her menses commenced at twelve and were regular, but for the past 
two years the flow has lasted about twice as long as heretofore. 
Since December there has been an almost continuous bloody dis- 
charge, at times profuse. 

About two years ago the patient commenced to have pain in the 
lower abdomen. This pain lasted about six months. For the last 
three years she has been short of breath, and since August, 1897, 
her feet have been swollen. For several months there has been a 
profuse yellowish leucorrhoeal discharge. 

First operation, March 24, 1898. Myomectomy per vaginam; 
evacuation of a pelvic abscess. A polyp was removed through the 



SUBMUCOUS ADENOMYOMATA 159 

vagina. The uterine cavity at this time varied from 10 to 12 cm. 
in length and in the posterior wall was a myoma. The pelvic 
abscess was opened and a small amount of necrotic material and pus 
came away. 

Second operation, April 27, 1899. Hystero-myomectomy, right 
salpingo-oophorectomy. There were general intestinal adhesions 
and the bladder was markedly lifted up. A right tubo-ovarian ab- 
scess was removed together with a myomatous uterus. Conva- 



i 










y'a. 



.■■.:.'■■>>'■ C 

Fig. 46. — Submucous adenomyoma of the uterus. (7 diameters.) 

Gyn.-Path. No. 2250. Nearly all trace of the mucosa formerly covering the 
growth has disappeared. Nevertheless, some of the stroma remains and is recognized at a. 
In some places are a few isolated uterine glands (6). The growth is composed chiefly of myomatous 
muscle and at points c c are the characteristic islands of uterine mucosa, consisting of glands 
enveloped in the usual amount of stroma. Scattered here and there throughout the growth are 
isolated glands, some surrounded by, others devoid of, stroma, d is a dilated gland. , 

lescence was uninterrupted save for slight swelling of the legs, not 
associated with anj^ pain or with any urinary disturbances. 

The temperature at the first operation reached 102° F. on the 
third day, but was normal by the ninth day. After the second opera- 
tion it rose to 101.4° F. on the second day and remained below 
100° F. after the sixth day. 

Gyn.-Path. No. 22 5 . — The specimen consists of a 
submucous nodule measuring approximately 4.5 by 2.5 by 1.5 cm. 
Its surface is roughened. On section it presents the usual myo- 



160 ADENOMYOMA OF THE UTERUS 

ma tons appearance, but just beneath the surface at one point is a 
cystic space 5 mm. in diameter. 

Histological Examination . — The surface of the 
myoma is over a considerable area covered with thinned-out mucosa 
without any surface epithelium (Fig. 46). The glands are few in 
number, are small, and have a normal epithelial lining. The stroma 
of the mucosa is fairly dense and near the surface contains numerous 
small blood-vessels. The myomatous tissue presents the usual 
appearance, but here and there, in the depth of the tissue, are groups 
of small tubular or slightly convoluted glands resembling in every 
particular uterine glands and surrounded by a stroma similar to that 
of the uterine mucosa. Occasionally one or two isolated glands are 
found lying in direct contact with the muscle. The small cystic 
space noted macroscopically is a dilated gland. 

Diagnosis . — Submucous adenomyoma of the uterus. 

Gyn. No. 6855. Path. No. 3107. 

Submucous adenomyoma. (See page 149 for the 
subsequent hysterectomy.) 

A. B. W., white, aged thirty-four, married. Admitted April 20, 
1899; discharged June 1, 1899. The patient has had three children, 
the oldest thirteen, the youngest nine. The menstrual history is 
normal, but there has been a profuse and offensive leucorrhoea for 
the last month. The patient has had prolapsus since the birth of 
her first child, thirteen years ago. One year ago some operation was 
performed, apparently a removal of a submucous nodule. Six 
weeks ago the patient noticed that there was a tumor protruding 
from the cervix. During the last two weeks there has been slight 
hemorrhage. The patient feels that she is growing weaker and has 
lost flesh. She has not been able to do any work for the last six 
weeks. 

Operation . — A vaginal cyst, measuring 3 by 2 cm., 
was removed from the left side, just behind the hymen. There was 
a myomatous growth, 4 by 3.5 by 4 cm., protruding from the cervix. 
This was drawn well down and ligated, and a large tubo-ovarian 



I 



SUBMUCOUS ADENOMYOMATA 161 

abscess on the right side was opened and thoroughly drained. Con- 
valescence was uninterrupted. 

Path. No. 3107 . — The specimen consists of a sub- 
mucous myoma and of a vaginal cyst. The myoma measures 4 by 
3 by 1.5 cm., is irregular in shape and somewhat discolored. On 
section it is hard and dense. 

Histological Examination . — The myoma pre- 
sents the usual appearance. Blood-vessels are abundant and, as a 
rule, small. In one section the protoplasm appears to be swollen, 
pale-staining, and has somewhat the appearance of fibrous tissue. 
At another part of the tumor gland-like spaces are seen, two of them 
being in close proximity to each other, and three some distance away. 
They are lined with a single layer of cylindrical epithelium. The 
specimen is a submucous adenomyoma in which the gland elements 
are few in number. 

Gyn. No. 10,314. Path. No. 6531. 

Double vagina; double cervix; large sub- 
mucous adenomyoma with the glands origi- 
nating trom the uterine mucosa and contain- 
ing quantities of miniature uterine cavities 
(Fig. 47). 

E. K., white, aged fifty, married. Admitted March 7, 1903; 
discharged April 17, 1903. Complaint: uterine hemorrhages. Her 
father died of dropsy; her mother of cardiac failure. She had 
scarlet fever at thirteen, but otherwise was healthy until the present 
illness. Her menses were normal until ten years ago. Since then 
she has had considerable pain at her periods, which came on at ir- 
regular intervals, from two to five weeks, and were more profuse 
than usual. She has been married twenty-one years, but has never 
been pregnant. For two years the periods have been profuse, 
coming on every two to three weeks, accompanied by much pain. 
She has lost 18 or 20 pounds. The patient is fairly well nourished; 
the haemoglobin 55 per cent. Fine crackling sounds are heard over 

the right upper back and lower right front. On vaginal examination 
11 



162 



ADENOMYOMA OF THE UTERUS 



a double vagina, with the septum extending the entire length of the 
vault, a double cervix and a double cervical canal were discovered. 
There was a submucous myoma within the uterus. This was appar- 
ently the size of a goose's egg. 
Operation . — The sep- 
tum was first removed and the 
myoma brought away in frag- 
ments. Her highest post-oper- 
ative temperature was 100° F. 
on the second day. On the 
twenty -first day there was phle- 
bitis of one of the small veins in 
the left leg. The patient was 
discharged well on the twenty- 
seventh day. 

Path. No. 6531.— 
The specimen consists of a 
large mutilated submucous my- 
oma, measuring approximately 
11 by 7 by 7 cm. On section 
it presents the typical myoma- 
tous appearance. Scattered 
throughout it, however, are nu- 
merous irregular islands of mu- 
cosa. At other points 
are spaces fully 8 mm. 
long by 2 mm. broad, 
lined with mucosa, 
which almost com- 
pletely fills the cav- 
ity (Fig. 47). They are 
easily recognized as 
miniature uterine cavities. All these spaces are 
dilated and are filled with chocolate-colored contents, evidently 
old menstrual hemorrhages. 




Fig. 47.^ — Submucous adenomyoma of the 
uterus, the myomatous muscle being 
riddled with miniature uterine cavi- 
TIES. (Natural size.) 

G y n . - P a t h . No. 6531. This is a 
longitudinal section of the mutilated submucous 
myoma which was associated with a double 
vagina and a double cervix. The greater part of 
the tissue consists of myomatous tissue, diffuse 
in character. On the left is a partial covering of 
normal uterine muscle (a). Scattered every- 
where throughout the myomatous tissue are 
collapsed and dilated miniature uterine cavities. 
b, b, are collapsed cavities, lined with a definite 
mucosa, c is a slightly dilated cavity likewise 
lined with mucosa, while d represents a miniature 
uterine cavity distended with blood. These 
cavities on histological examination are found, as 
their names would imply, to be lined with typical 
uterine mucosa. 



SUBMUCOUS ADENOMYOMATA 163 

On histological examination the specimen pre- 
sents a typical myomatous appearance. Scattered throughout the 
muscle are miniature uterine cavities, some of them reaching 1 cm. 
in length; also islands of perfectly normal uterine mucosa. The 
glands lining these miniature cavities, and also forming the islands 
of perfectly normal mucosa, are accompanied by the usual stroma. 
Here and there a gland is dilated or has a cavity filled with old men- 
strual clots which have become partly disorganized. The spaces 
contain fragments of nuclei and polymorphonuclear leucocytes, 
while surrounding them are many small connective-tissue cells, some 
containing granular pigment and remnants of blood. At other points 
the blood is still well preserved. xVt some points are spaces fully 
2 mm. in length, evidently dilated glands. They are lined with 
cylindrical epithelium resting on a stroma which separates them from 
the muscle. The uterine mucosa in a few places is preserved. Over 
the myoma here and there one is ah\e to trace 
the uterine mucosa as it penetrates into the 
depth. 

We have in this case a typical submucous adenomyoma, where 
we are able to show that the gland elements are derived from the 
normal uterine mucosa. 

Gyn. No. 10,872. Path. No. 7076. 

Submucous adenomyoma. 

H. D., single, aged thirty-three, colored. Admitted November 
12, 1903; discharged December 11, 1903. The patient complains 
of a water\^ discharge which has persisted for six months. This has 
at times been profuse. The patient is well nourished, but her hae- 
moglobin is only 60 per cent. The entire vagina is filled with a 
globular mass which projects from the cervical canal. This tumor 
was bisected and found to be attached by a small pedicle which was 
tied off. Her highest post-operative temperature was 100.5° F. 
When she left the hospital her haemoglobin was still 60 per cent. 

Path. No. 7 76 . — The specimen consists of a bi- 
sected, considerably mutilated myoma measuring 10 by 7 by 4 cm. 



164 ADENOMYOMA OF THE UTERUS 

On section the tumor presents the usual appearance save for three 
cystic spaces, each about 1 cm. in diameter, and filled with fluid. 
These have smooth inner linings. 

On histological examination the myoma shows 
marked richness in muscle cells. There is also considerable hyaline 
degeneration. The cyst walls are lined with cylindrical epithelium 
similar to that of the uterine mucosa. 

Diagnosis . — Submucous adenomyoma. 



CHAPTER VII 
CERVICAL ADENOMYOMATA 

From the study of adenomyomata of the body of the uterus we 
have seen that, in the first place, there is a diffuse myomatous thick- 
ening of the inner muscular walls accompanied by a down-growth 
of the normal mucosa into this diffuse growth. Portions of this 
adenomyoma may become subperitoneal or intraligamentary, and 
often form a large cystic adenomyoma. Portions of the diffuse 
growth were also found to project into the uterine cavity, forming 
submucous adenomyomata. Should an adenomyoma develop in 
the cervix, we would expect it, judging from analogy, to consist of 
cervical glands enclosed in a tissue made up of myomatous muscle 
and the dense stroma characteristic of the cervical mucosa. In Case 
3898 (Fig. 48) we found a small myomatous uterus, in which rem- 
nants of an adenomyoma were present along the outer border of the 
cervix, i. e., near the broad ligament or vaginal attachment. A 
glance at Fig. 49 shows that the glands in this small growth corre- 
spond to those of the body of the uterus, and in addition they are sur- 
rounded by the usual stroma found in the mucosa above the internal 
OS. Landau and Pick^ report a case in which the cervical canal was 
entirely obliterated by an adenomyomatous nodule which com- 
pletely shut off the uterine cavity from the vagina. In this case 
also typical uterine glands with their accompanying stroma were 
the epithelial elements present. 

In 1896 when reporting two typical cases of diffuse adenomyoma 
of the body of the uterus^ I described an adenomyoma of the cervix 

^Landau, L., and Pick, L.: Ueber die mesonephrische Atresie der Miiller'schen 
Gange, zugleich ein Beitrag zur Lehre von den mesonephrischen Adenomyomen des 
Weibes und zur Klinik der Gynatresien. Arch. f. Gynak., 1901, Bd. Ixiv, S. 98. 

^Cullen, Thomas S.: Adenomyoma Uteri Diffusum Benignum. Johns Hopkins 
Hospital Reports, vol. vi. 

165 



166 ADENOMYOMA OF THE UTERUS 

consisting of cervical glands, muscle, and a moderate amount of 
fibrous tissue. This finding is ven^ rare, as from the literature I 
have been unable to glean a single similar case. In Fig. 23, p. 77, 
a round submucous nodule, 2.5 cm. in diameter, is seen projecting 
from the cervix. 

On histological examination the outer surface 
of the nodule is found to be in places covered with cylindrical epithe- 
lium. Scattered everj" where throughout the muscle are gland- 
like spaces varsdng from a pin-head to 3 mm. in diameter. These 
are lined with a single layer of epithelium, which in the smaller 
glands is of the high cylindrical variety. In the dilated glands, 
however, it is cuboidal or has become almost flat. The cell pro- 
toplasm takes the haematoxylin stain, as is so characteristic of the 
cervical epithelium. The nuclei are oval and vesicular, and in many 
places it is possible to make out cilia. The gland cavities are empty 
or contain a granular material that takes the haematoxylin stain. 
The glands tally in evers^ particular with the cervical glands. This 
nodule is undoubtedly a cervical m3^oma and appears to be the only 
one of its character on record. It has evidently started near the 
internal os. Otherwise we would not have had so much muscular 
tissue. 

Gyn. No. 3898. Path. No. 934. 

Submucous and interstitial myomata and 
an adenomyoma situated near the broad lig- 
ament attachment of the cervix (Figs. 48 and 49). 
General pelvic peritonitis, left side hydro- 
salpinx simplex; small papillocystoma of 
the ovary. 

M. J., married, aged thirty-eight, white. Admitted October 22, 
1895. This patient has never been pregnant. The menses began 
at thirteen and were regular until four j^ears ago. Since then they 
have occurred at intervals of from two to ten weeks. At these times 
the flow is often profuse, at other times scanty. 

Four years ago a tubo-ovarian cyst was removed by Dr. Senn. 



CERVICAL ADENOMYOMATA 167 

Two years ago she had several hemorrhages, and during the next 
year was curetted four times. For ten years she has felt a stabbing- 
like pain at intervals in the left ovarian region. Two years ago she 
noticed a swelling in the left side and the enlargement reached half- 
way to the umbilicus. This appeared suddenly, and gradually 
disappeared in the course of six weeks. Since Januar}^, 1895, she 
has had a burning pain in the right ovarian region. 

Operation, October 23, 1895. Hystero-salpingo-oophor- 
ectomy. Removal of haematoma in the right broad ligament and 
a left hydrosalpinx. Adhesions were found binding down the tube 
and ovary and there was encysted peritonitis. The myomatous 
uterus choked the pelvis. The omentum, rectum and small in- 
testine were densely adherent. During removal of the uterus the 
external coats of the ileum were ruptured in one place, requiring 
three sutures. 

After the operation the temperature gradually rose, reaching 
103.2° F. on the day of her death. 

On the second day after the operation the patient complained 
of excruciating pain in the right side over the site of the intestinal 
suture. This became more and more intense and abdominal dis- 
tention developed. The abdomen was opened without anaesthesia 
and a perforation of the intestine found at the site of the intestinal 
suture. The patient died that same evening. 

Gyn.-Path. No. 934. The specimen consists of the 
uterus, the left tube and ovary, portions of the wall of a haema- 
toma from the right side, also of a small piece of the abdominal wall. 

The uterus measures 7.5 by 5 by 7 cm. and is covered with vas- 
cular adhesions. Projecting from the anterior surface is a sessile 
nodule, 5.5 by 5 by 4 cm. This for the most part is smooth and 
glistening, but shows a few delicate vascular adhesions on its under 
surface. On its right side it presents a slighth^ convoluted appear- 
ance and over an area 1.5 cm. is covered with a yellowish tissue re- 
sembling mucous membrane. The uterine cavity is 4.5 cm. in length 
and 3 cm. in breadth at the fundus (Fig. 48). Its mucosa presents a 
finely granular surface, but is smooth and glistening and the upper 



168 



ADENOMYOMA OF THE UTERUS 



portion shows considerable ecchymosis. Projecting into the cavity 
at the left cornu is a fold of mucous membrane, 5 by 2 mm. The 
uterine walls are occupied by numerous firm white nodules varying 
from .5 to 4.5 cm. in diameter. All of the nodules present the typical 
myomatous appearance. 

Right side: The tissue removed consists of portions of the wall 




Fig. 48. — Interstitial uterine myomata with a small diffuse adenomyoma in the cervix. 

(Natural size.) 
Gyn.-Path. No. 934. The uterus has been amputated through the cervix and 
opened anteriorly. Situated in the anterior wall is a myoma. This has not been cut through the 
centre and consequently one portion is larger than the other. Near the uterine cavity is a myoma , 
about 1 cm. in diameter. This has been cut in two. The uterine walls, were it not for the myo- 
mata, would be of normal thickness. The uterine cavity is of the normal length and its mucosa 
unaltered. On the right side of the cervix at a point approximately corresponding to a was a small 
diffuse adenomyomatous thickening, part of which is represented in Fig. 49. 

of a hsematoma. (The appendages had been removed at a previous 
operation.) 

Left side: The tube at a point 1.5 cm. from the uterus is 4 mm. 
in diameter, but gradually dilates, and after passing outward for 
6.5 cm. forms with the ovary a tubo-ovarian mass, measuring 6 by 
5 by 2.5 cm. The tube is covered with dense adhesions, has thin 
transparent walls, through which the folds of the mucosa can be 
seen, and contains a clear transparent fluid. The tubo-ovarian mass 



CERVICAL ADENOMYOMATA 169 

has been, for the most part, converted into a thin-walled cyst con- 
taining clear transparent fluid. The ovary also contains a firm, 
oval, movable body, 1.3 by 8 cm. This, on section, is seen to be 
made up of numerous small cysts, in the walls of which calcareous 
material has been deposited. 

Histological Examination . — The cervical glands 
present the usual appearance. The uterine mucosa is normal in 
thickness; its surface epithelium is intact and its glands are abun- 



.u-.- 



c . 



d— 



.<--v. -'Jsr* 




a 

Fig. 49. — Adenomyoma in the outer portion of the cervix near the broad ligament 

ATTACHMENT. (4 diameters.) 

Gyn.-Path. No. 934. The section is through the right side of the cervix in Fig. 
48 at a point approximately indicated by a. a is the normal cervical mucosa. The surface 
epithelium is intact and the characteristic racemose glands are seen. Beneath them is the normal 
stroma. At b is an island of mucosa situated in myomatous muscle. The glands in this island 
resemble uterine glands. Some of them are dilated. At c and c they spread out in "goose 
march" fashion — that is, in single file. All of these glands are surrounded by the characteristic 
stroma. At d are seen isolated glands lying in direct contact with the muscle. 

dant and slightly convoluted. A few are dilated, but all have an in- 
tact epithelium and many of them contain hyaline material. Here 
and there a gland extends a short distance into the muscle, being ac- 
companied by stroma. The stroma of the mucosa in its superficial 
portion shows slight hemorrhage. 

All of the nodules scattered throughout the uterus present the 
typical myomatous appearance and the large nodule in the anterior 
wall shows considerable hyaline degeneration. The whitish-yellow 
area attached to the right side of the uterus, and resembling mucous 



170 ADENOMYOMA OF THE UTERUS 

membrane, is covered with one layer of cylindrical epithelium, on 
which it is in places possible to detect cilia. Beneath the epithelium 
is a varjdng amount of stroma similar to that of the uterine mucosa. 
This stroma shows considerable small round-cell infiltration and 
has here and there throughout it oval or round glands lined with 
cylindrical epithelium. The tissue external to this stroma is com- 
posed of non-striped muscle fibres and connective tissue. Scat- 
tered throughout this muscular tissue are 
glands, in some places as many as eight being 
seen on cross-section (Fig. 49) . Some are oval or round, 
others are dilated. All have an intact epithelial lining and in many 
places it is possible to make out cilia. These glands are surrounded 
by the typical stroma. Scattered here and there throughout the 
thickened wall are numerous glands, some lying in the myomatous 
muscle immediately beneath the peritoneum, others in what appears 
to be normal muscle. Some of the glands contain blood and one has 
become cystic. The growth is an intraligamentary adenomyoma, 
but its exact relations cannot be determined, as the tissue was much 
mutilated during operation. 

Left side: The tube is covered with dense adhesions, but its 
mucous membrane is normal. The cyst of the ovary is apparently 
lined with a single layer of epithelium ; it has several papillar}^ masses 
springing from its inner surface. 

Diagnosis . — Submucous and interstitial myomata. Cer- 
vical adenomyoma. Normal uterine mucosa. General pelvic peri- 
tonitis. 

Left side : Hydrosalpinx simplex. Small papillocy stoma of the 
ovary. 



CHAPTER VIII 

CONDITION OF THE TUBES AND OVARIES WHEN ADENOMYOMA OF 

THE UTERUS EXISTS 

In forty-five cases we have carefully examined the tubes and 
ovaries to see if there might be any causal relation between them and 
the development of adenomyoma in the uterus. We have failed to 
find proofs of any such relation. In fifteen cases we found the ap- 
pendages on both sides normal. In the remaining thirty cases the 
appendages on one or both sides were covered with adhesions, there 
being a mild degree of pelvic peritonitis, in part probably due to the 
discrete myomatous growth, but to a greater extent undoubtedly 
caused by the diffuse mj^oma. In Case 2806 there was a right 
tubo-ovarian abscess and a partially healed salpingitis on the left 
side. The left ovary in Case 3136 contained a small cyst; in Case 
3898 the left tube was the seat of a hydrosalpinx, the left ovary 
of a small papillocy stoma. There was a very large multilocular 
cystadenoma of the left oysltv in Case 4364. 

In a few cases there was a healed salpingitis. In Gyn. No. 2706 
and in Path. No. 8393 a hydrosalpinx was present. In Gyn. No. 
12,080 an acute salpingitis was found, and in Gyn. No. 2806 
a tubo-ovarian abscess. 

Where pelvic adhesions are present the normal maturing of the 
follicle is often interfered with, and we consequently find small Graafian 
follicle or corpus-luteum cysts. In Gyn. No. 2706 we found an ova- 
rian cyst measuring 13 by 12 by 11 cm.; in Gyn. No. 3898 a very 
small papillocystoma of the ovary. In Gyn. 9457 one ovary con- 
tained a large cyst with changes very suggestive of an early car- 
cinoma. These pathological changes in the ovaries are not in ex- 
cess of those usually found in a corresponding number of abnormal 
adnexa examined in the laborator}^ Adenomyoma of the uterus 

171 



172 ADENOMYOMA OF THE UTERUS 

does not seem to materially increase the incidence of pathological 
changes in the tubes or ovaries. 

In forty-nine cases in which we examined the uterus for adhe- 
sions, in twenty-five the organ was perfectly smooth and in twent}^- 
four was more or less adherent. The adhesions, as a rule, were con- 
fined to the posterior surface of the organ; only rarely was the an- 
terior surface implicated. 



CHAPTER IX 
THE CLINICAL PICTURE IN CASES OF ADENOMYOMA OF THE UTERUS 

This will, of course, vary with the situation of the growth and also 
with the size and situation of the discrete myomata so often asso- 
ciated with adenomyoma. 

Where the diffuse growth is the chief factor, the patient usually 
gives a history of lengthened menstrual periods, accompanied by a 
great deal of pain, sometimes limited to the uterus, but often also 
referable to the back and extending to the legs. This pain may be 
dull, aching, or grinding in character. As the disease progresses 
the menorrhagia ma}^ be replaced b}^ a continuous hemorrhagic dis- 
charge, as was observed in Cases 2573 and 6083 ; or alarming bleeding 
may occur, as in Case 7153. This hemorrhage is readily 
accounted for when w^e take into consideration the greatly increased 
amount of uterine mucosa existing under such circumstances, com- 
prising that lining the uterine cavity and also that liberalty dis- 
tributed throughout the diffuse myomatous growth. The pain 
is also easily explained when we remember that the myomatous 
tissue is treated as a foreign body. In cases of discrete myomata 
there is also pain, but the uterus readily forces the nodule toward 
the peritoneal or submucous surface. In the diffuse growth, while 
this is also possible, the difficulties in its accomplishment are much 
greater, as the mass is so intimately interwoven with the normal 
muscle. At each menstrual period the uterine mucosa is congested 
and thickened. In adenomyoma with an increased amount of blood 
in the islands of the mucosa scattered through the diffuse growth we 
should naturally have increased tension, producing a tenderness or 
sharp pain, referred to the uterus, during the period. 

Discharge. — In analyzing the clinical histories of thirty-seven 
cases for vaginal discharge we find that twenty-six were free 
from any flow between menstrual periods or between hemorrhages. 

173 



174 ADENOMYOMA OF THE UTERUS 

In eleven there was a distinct flow, chiefly leucorrhoeal in character 
and usually non-irritating. In a few instances it was greenish or 
yellowish in color and offensive. In case No. 3192 there was a fre- 
quent white discharge and in Sanitarium No. 1944 a watery dis- 
charge was present. This might readily be accounted for, as the 
patient had a haemoglobin of only 40 per cent. We are naturally 
surprised to see that so few of the patients gave a distinct historj'- of 
vaginal discharge. When we remember, however, that the uterine 
mucosa and that situated deep down in the muscle are practically 
normal, this relative absence of the vaginal discharge is readily ex- 
plained. In those cases in which the adenomyoma becomes sub- 
peritoneal or intraligamentary and forms large cysts, pressure symp- 
toms may occur, and such cysts are usually firmly fixed in the pelvis. 
This is especially true of the intraligamentar}^ variety, where the 
tumor is prevented from rising into the abdomen by the broad liga- 
ment. 

Age. — We have found this disease in women as young 
as nineteen and as old as sixty. In sixty-six patients in whose cases 
the age was obtained the following incidence was noted : 

At nineteen 1 case 

Between twenty and thirty 3 cases 

Between thirty and forty 21 " 

Between forty and fifty 19 " 

Between fifty and sixty 21 " 

At sixty 1 case 

This table goes to show that the period between the fourth and sixth 
decades presents the highest incidence of this disease. The pro- 
cess seems to be a slow one, as is evidenced by the clinical history. 
Some patients dated their trouble back five or ten j^ears, while others 
had been complaining for only a few months. W^e have found this 
disease equally prevalent in the colored and white races. 

Relation to Pregnancy. — We have examined the clinical histories 
in forty-nine of the cases of diffuse adenomyoma of the uterus to 
determine the relative frequency of pregnancy, with the following 
results : nine patients were single, six were sterile, two had had mis- 
carriages, thirty-two had had children. 



CLINICAL PICTURE IN ADENOMYOMA OF UTERUS 175 

One of the sterile patients had not married until over fort}^ years 
of age, and accordingly might be equally well classed with the single 
patients from that standpoint. 

In thirty-one of the thirty-four patients that had had either 
children or miscarriages we have accurate records of the number of 
children. In all, one hundred and forty-one children were born, 
approximately four children to each woman. In a few instances a 
woman had had only one child, while in one case the patient was the 
mother of thirteen, in anotlier of eleven, in a third case of ten. These 
figures show that the disease is found in single as well as in married 
women, and furthermore that it does not seem in any way to militate 
against normal pregnanc^^ 

Physical Examination. — On making a vaginal examination, 
when the growth is confined to the uterus we find the cervix 
practical^ normal, the body of the uterus considerably enlarged 
and very hard. In the majority of the cases we also feel definite 
small round bosses due to discrete myomata. In the early cases the 
organ may be free, but very often it is enveloped in adhesions and 
firml}' fixed. In some cases (Fig. 13) the organ will be symmetrical, 
very firm, and the size of that of a two or three months' pregnanc3^ 
Where the growth is large and cystic and lies in the abdominal 
cavity, it is impossible to differentiate it from an ordinary myoma- 
tous uterus pure and simple or associated with an ovarian cyst. 
If the growth be intraligamentary, it is more firmly fixed in the 
pelvis, and is then comparable to a broad ligament myoma or to an 
intraligamentary cyst, although it may simulate a large pelvic ab- 
scess. The clinical history of pus will, however, be wanting. 

From the preceding it will be seen that if we have a patient giv- 
ing a history of an ever-increasing menstrual flow, and showing on 
pelvic examination a moderately enlarged and firm and possibly 
nodular uterus, which on curettage yields a rather thick but normal 
mucosa, we may reasonably suspect an adenomyoma. Of course, 
however, the hemorrhages may occasionally be due entirety to the 
presence of discrete submucous myomata. 

Where carcinoma of the body of the uterus is present the organ 



176 



ADENOMYOMA OF THE UTERUS 



is likely to be soft. Rarely small and isolated myomata are found 
on its surface, and curettage yields adenocarcinoma instead of 
normal mucosa. 

Where an adenomyoma is subperitoneal or intraligamentarj^ the 
diagnosis is impossible until the abdomen is opened. But then, 
given a m3^omatous uterus containing large cystic areas with smooth 
velvety linings and chocolate-colored contents, adenomyoma will 




/^r»-*-^ 



Fig. 50. — A cystic myoma macroscopically simulating a cystic adenomyom.a.. (§ natural 

size.) 

Path. No. 10, 771. The picture represents a cross-section through the tumor as seen 
in the upper left corner, the section being made from a to a'. A small portion of the uterine 
cavity is seen. On one side of it are cross-sections of two simple myomata. At b we have a cystic 
myoma with a slightly irregular cavity that was filled with chocolate-colored blood. We felt con- 
fident that a histological examination would reveal a cystic adenomyoma. The walls of the cavity 
were, however, composed of myomatous tissue that had undergone partial hyaline degeneration 
and the cavity was totally devoid of any epithelial lining. There had evidently been simple 
cystic formation as a result of the breaking down of hyaline tissue. Hemorrhage had taken place 
later. This is the only one of our cases in whicli a tumor presented such a gross appearance 
and did not yield adenomyoma on histological examination. 



usuall}^ be found. Fig. 50 represents the only exception that we 
have noted. Here the uterus contained several myomata. One of 
them had a central cavity which was filled with chocolate-colored 
contents. This myoma had undergone a good deal of hyaline de- 
generation. In the centre was a cystic area and into this hemorrhage 
had taken place. It was not an adenomyoma. 



CHAPTER X 

DIFFERENTIAL DIAGNOSIS IN CASES OF ADENOMYOMA OF THE 

UTERUS 

Diffuse adenomyoma of the uterus has, thanks to the work of 
von Reckhnghausen, become a definite pathological entity, but here- 
tofore it has not impressed surgeons as having a very definite and 
peculiar train of symptoms. 

In the early years of our investigations we also failed to detect 
it clinically, but in the early and fairly advanced stages of the process 
so definite are the symptoms that the hospital assistant now fre- 
quently comes and says that a given case has all the signs of an 
adenomyoma and that he feels sure that this is the cause of the 
bleeding. His diagnosis can, of course, be greatly strengthened by 
the histological appearances of the uterine mucosa, and then the 
gross appearance of the uterine wall on section often suffices to 
clinch the diagnosis after the uterus has been removed, even before 
a histological examination has been made. We accordingly see that 
this disease has very characteristic symptoms and must be given its 
proper place in our list of uterine diseases which may be clinically 
recognized. 

Clinically adenomyoma has to be differentiated from any pelvic 
condition that may cause uterine hemorrhage. The following are 
those diseases that are likely to produce or be associated with uterine 
bleeding. 

1. Uterine polypi. 

2. Large venous sinuses in the mucosa. 

3. Marked proliferation of the stroma of the mucosa. 

4. Verj^ large and dilated uterine glands with overgrowth of the 
stroma of the mucosa. 

5. Uterine myomata. 

6. Sarcoma. 

12 177 



178 



ADENOMYOMA OF THE UTERUS 



7. Abortion. 

8. Chorio-epithelioma. 

9. Tubal pregnancy. 

10. Salpingitis and endometritis. 

11. Carcinoma of the uterus. 







.«s*i-^. 



■'^u. 



H't 






Fig. 51. 



H B 



(4 



UTERINE POLYPI 

These may be situated in the cervix or body, and are usually 
associated with a slight irritating uterine discharge and often with 

bleeding. This bleeding may 
manifest itself as an exacerba- 
tion of the usual flow at the 
period or there may be a slight 
discharge of blood between 
periods. 

If the growth projects through 
the cervix, the recognition of the 
polyp is easy and its removal is 
followed by a total cessation of 
the symptoms. Should the polyp 
be in the cavity of the uterus, it 
may be brought away with the 
curette, and then all symptoms 
cease. 

Polypi, whether situated in 
the cervix or in the body, are 
nothing more than portions of 
normal mucosa which have for 
some reason been partially or 
completely extruded (Fig. 51). 

On histological examination 
they are recognized by their oval 
or oblong shape and by the fact that they are covered on three sides 
by epithelium. 

In cases of diffuse adenomyoma curettage gives only temporary 



-A SMALL UTERINE POLY 

diameters.) 

Gyn.-Path. No. 659. This 
section is from the fundus of the uterus. 
The mucosa lining the uterine cavity is rather 
thin.j and has a smooth surface covered with 
one layer of epithelium. Scattered through- 
out the mucosa are a small number of nor- 
mal uterine glands. Projecting from it is a 
tongue-shaped polyp (a), which points down- 
ward. Its surface is covered with one layer 
of epithelium, continuous with that covering 
the surface of the mucosa. Its substance 
contains glands differing from those in the 
mucosa only in that a few of them are dilated. 
The stroma of the polyp merges impercep- 
tibly into that of the normal mucosa and is of 
the same character. It is evident that this 
is in reality the result of a partial extrusion 
of the normal mucosa. 



DIFFERENTIAL DIAGNOSIS 



179 



relief, and on histological examination nothing but perfectly normal 
mutosa can be detected in the scrapings. 

LARGE VENOUS SINUSES IN THE UTERINE MUCOSA CAUSING FREE 

HEMORRHAGES 

In " Cancer of the Uterus" I reported a case in which, on account 
of the frequent uterine hemorrhages, carcinoma was suspected and 
hysterectomy contemplated. Examination of the scrapings showed 



\M 






^■-^:^ ;:'7'f?r;;^;--^;;^ 






^H 










W-^r-::;^^ 



Jf,^ecj(0r. 



Fig. 52. — Large venous sinuses in the utekine mucosa causing severe hemorrhages. 

(80 diameters.) 

Gyn.-Path. No. 2048. a is a portion of the surface epithelium, which is 
greatly flattened. In the lower part, as well as in the upper third of the field, are several uterine 
glands of the usual size and shape, and lined with one layer of cylindrical epithelium. They 
are perfectly normal, and are surrounded by the normal stroma of the mucosa. Over one half 
of the section is made up of three large venous sinuses (6), showing exceedingly delicate walls. 
That there is no malignant process is clear. It is little to be wondered at that free hemorrhages 
should have taken place, when such large blood sinuses existed. 



that the bleeding was due to enormous sinuses scattered throughout 
the uterine mucosa. The patient was greatly benefited by the curet- 
tage. A year later she was again curetted, and in a short time she 
felt better than she had for years. 



180 ADENOMYOMA OF THE UTERUS 

The difference between the mucosa in this case and that in a case 
of adenomyoma is very plain, as can be gathered from Fig. 52. 

MARKED PROLIFERATION OF THE STROMA OF THE MUCOSA ASSOCIATED 
WITH COPIOUS UTERINE HEMORRHAGES 

On page 478 of " Cancer of the Uterus" I described several cases 
in which free uterine hemorrhage was apparently due to a marked 
proliferation of the stroma of the uterine mucosa, the glands re- 
maining perfectly normal. The stroma was very rich in cellular 
elements; the nuclei were slightly larger than normal. Numerous 
nuclear figures could be seen scattered throughout the stroma, and 
were it not for the fact that the spaces between the glands were every- 
where approximately equal, one might have suspected sarcoma. 

The histological picture shows clearly the difference in the mucosa 
of cases of this character and those of diffuse adenomyoma. Clinic- 
ally, the contrast is even more striking. All the patients were under 
twentj^-five years of age and in each case the hemorrhages ceased in 
the course of a few vears. 



A THICK UTERINE MUCOSA; VERY LARGE AND DILATED UTERINE GLANDS 
WITH AN OVERGROWTH OF THE STROMA OF THE MUCOSA 

Clinically we have a by no means small group of cases in which 
a patient, usually between forty and fifty, comes complaining of 
a very profuse menstruation and at times of an intermenstrual flow 
or a leucorrhoeal discharge, and in which carcinoma of the body of 
the uterus is suspected. 

On histological examination we find a most characteristic picture 
(Fig. 53). The mucosa is much thickened. The glands are large 
and many of them are dilated. This dilatation is, however, not due 
to occlusion and cyst formation, as the gland epithelium is proliferated 
and higher than usual instead of flattened. Many of the enlarged 
glands are irregular in outline. 

The stroma of the mucosa is very rich in cell elements and nu- 
clear figures can at times be detected. 

I have examined the mucosa in many such cases and am at a 



DIFFERENTIAL DIAGNOSIS 

b 



181 




Fig. 53. — Thickening of the uterine mucos.\. Marked dilatation of some of the glands 
WITHOUT any atrophy OF THEIR EPITHELIUM; VERY DENSE STRO.MA. (38 diameters.) 

Gyn.-Path. No. 7026. The section is a portion of a scraping. The surface epithe- 
lium is intact as seen as a and a. At b are two normal uterine glands. Fully half of the glands 
are more or less dilated. At c is an irregular and dilated gland filled with coagulated serum. 
d and e are also dilated but not spherical glands. The glantl / is marketUy dilated and spherical. 
In none of the dilated glands is there any atrophy of the epithelium. The stroma between the 
glands is very dense. In some of these cases large veins are found scattered throughout the 
stroma. Given such a mucosa as this, one can say with almost absolute certainty that the 
patient has had very profuse menstrual bleeding. 



182 ADENOMYOMA OF THE UTERUS 

loss to give the condition a definite name. With such a mucosa one 
can say with absolute certainty that the patient has been subject 
to ven^ free uterine bleeding. It is not malignant. 

The clinical picture in this condition resembles to some extent 
that of diffuse adenomyoma of the uterus, but, as noted, the histo- 
logical patterns are totally different. 

UTERINE MYOMATA 

Myomata are primarily interstitial and may become subperitoneal 
or submucous. Often these give rise to no symptoms whatever 
save those of pressure. When the myomata become submucous, 
more or less menorrhagia is present. This is due to the fact that the 
uterine mucosa is put on tension by the myoma, which is gradually 
forcing its way into the cavity of the uterus. I have known a small 
submucous myoma give rise to almost fatal hemorrhage, while, on 
the other hand, a patient with an 89-pound myoma had never had 
any excessive menstruation. The hemorrhage depends entirely 
on the situation of the tumor. 

Bimanual examination will often reveal the presence of a large 
myomatous uterus. 

On curettage normal or atrophic uterine mucosa will be found, 
provided the tubes and ovaries are normal. 

The differential diagnosis between a uterus containing simple 
discrete myomata and one the seat of a diffuse adenomyoma is often 
difficult, if one of the simple myomata be submucous. The difficulty 
is increased by the fact that there is a marked tendency for discrete 
myomata to be associated with a diffuse adenomyoma. How- 
ever, where simple myomata exist there may not be the marked 
tenderness at the menstrual period, so frequently noticed in adeno- 
myoma, and further, examination of the curettings will usually 
demonstrate a much thicker mucosa in the adenomyomatous 
uterus. 



DIFFERENTIAL DIAGNOSIS 183 

SARCOMA OF THE UTERUS 

In the examination of over twelve hundred myomata we have 
found sarcoma developing in or associated with uterine myomata 
in seventeen cases. 

The points of difference between cases of uterine myomata and 
diffuse adenomyoma apply equally well to those of sarcoma of the 
uterus. In sarcoma, however, we have a histor}^ of a tumor which 
has probably lain dormant for years, and then suddenly has com- 
menced to grow rapidly. If portions of the growth project into the 
uterine cavity, the diagnosis of sarcoma can readily be made from 
pieces removed with the curette. 

Where sarcoma arises primarily from the uterus and not from a 
pre-existing myoma, the growth may also be correctly diagnosed 
from scrapings, if portions of it project into the uterine cavity. 

ABORTION 

Uterine bleeding often follows a miscarriage, especiall}^ when 
remnants of the placenta have been left behind. This bleeding is 
usually continuous, while in adenomyoma the bleeding usually con- 
sists in an exacerbation of the menstrual period. Further, in the one 
case there is likely to be a historj^ of a recent conception; in the 
other the bleeding has been noticed for months or years and has 
gradually increased. 

Where an abortion has occurred placental villi or decidual re- 
mains are usually obtained on curettage. In diffuse adenomyoma a 
perfectly normal uterine mucosa is found. 

CHORIOEPITHELIOMA 

Chorioepithelioma is infinitely rarer than adenomyoma, and 
follows an intrauterine or extrauterine pregnancy — usually a hy- 
datid mole. 

The clinical history is generally sufficient. Examination of the 
scrapings will aid materially in settling the question. Where chorio- 
epithelioma exists we usually have placental villi showing marked 



184 ADENOMYOMA OF THE UTERUS 

proliferation of the syncytium and usually of Langhans' layer. 
There are also many vacuoles between and also in the masses of 
cells of the growth. 

While one cannot from the scrapings differentiate absolutely 
between a very active hydatid mole and chorioepithelioma, yet one 
can say with certainty that a pregnancy has existed and that the 
growth, if not actually malignant, is very suspicious. In the cases 
of diffuse adenom3^oma the mucosa is perfectly normal. 

TUBAL PREGNANCY 

Pregnancy in the Fallopian tube is usually associated with a 
cessation of the period for one or two months, followed by a slight 
continuous uterine bleeding. In some cases the periods have been 
perfectly regular, but the last period has never completely stopped 
and the patient has continued to lose a little blood. Later she com- 
plains of pain in one side, and if she does not consult a physician 
she suddenly collapses from internal hemorrhage. Pelvic examina- 
tion before rupture of the tube will show slight enlargement of the 
uterus with a small mass on one or the other side. 

In adenomyoma the periods remain regular, but are profuse, 
and there is usually no intermenstrual bleeding. Moreover, there is 
little or no intermenstrual pain. Examination of the uterine 
mucosa in the one case usually yields a slight decidual formation ; in 
the adenomyoma, a normal mucosa. 



SALPINGITIS AND ENDOMETRITIS 

The patient with pelvic inflammation usually gives a history of 
an acute infection followed by a profuse uterine discharge and pain 
laterally. Bleeding is occasionally present and may suggest adeno- 
myoma. 

On examination of the scrapings we usually find a thinning out 
of the mucosa and definite infiltration with small round cells or poly- 
morphonuclear leucocytes. In those cases in which tuberculosis is 
present typical tubercular areas or areas of caseation are seen. 



DIFFERENTIAL DIAGNOSIS 185 

Both pictures are totally different from that presented by the normal 
uterine mucosa associated with diffuse adenomyoma of the uterus. 



CARCINOMA OF THE UTERUS 

Carcinoma of the uterus is clinically divisible into two varieties: 

1. Carcinoma of the cervix. 

2. Carcinoma of the body of the uterus. 

Usually the first symptom of a carcinoma, whether situated in 
the cervix or body, is uterine hemorrhage. This is frequently sudden 
and may be meagre or abundant. The hemorrhages are usually 
intermenstrual. In adenomyoma the bleeding is usually profuse at 
the periods and there is no hemorrhage between the periods. In car- 
cinoma a watery or purulent and usually offensive discharge is pres- 
ent between the periods. This is due to disintegration of the de- 
generating carcinomatous tissue. In adenomyoma there is usually 
no such discharge because there is no dissolution of tissue. 

Where carcinoma of the cervix exists the growth can usually be 
detected on digital examination. Sometimes it is recognized as a 
cauliflower-like outgrowth from the cervical lips, but in the later 
stages a crater-like cavity is present where the cervix should be, 
and the vaginal vault is board-like in consistency as a result of car- 
cinomatous infiltration. In cases of diffuse adenomyoma of the 
uterus the cervix is usually perfectly normal. 

Where carcinoma of the body of the uterus exists, uterine scrap- 
ings yield the characteristic pattern of adenocarcinoma and the cell 
changes leave no doubt as to the malignant nature of the growth. 
In cases of adenomyoma the mucosa lining the uterine cavity is, on 
the contrary, perfectly normal. 



CHAPTER XI 
TREATMENT OF ADENOMYOMATA OF THE UTERUS 

Not infrequently the case will be looked upon as one of simple 
myoma and its true character will be determined only after opera- 
tion. Should a diagnosis be made, abdominal hysterectomy is in- 
dicated provided the bleeding is so severe that the patient's health is 
being undermined. Mj^omectomy is inapplicable, as the growth is so 
interwoven with the normal muscle that it cannot be shelled out. 
In cases of intraligamentarA^ and cystic adenomyomata evacuation of 
the cyst contents will often be found necessary, before it is possible 
to shell the tumor and the uterus out from the pelvic floor. As 
these growths will lift up the peritoneum of Douglas' sac, it will be 
advisable to dissect the peritoneum back so that it can be replaced 
after removal of the tumor, thus avoiding a raw area on the 
pelvic floor. If this precaution be not taken, intestinal loops are 
apt to drop down and become adherent. 

In these cases supravaginal hysterectomy is all that is required. 
This occasional^ greatly diminishes the dangers of the operation. 
For example, in one of our recent cases in which we suspected carci- 
noma of the body a complete abdominal hysterectomy was com- 
menced. Release of the cervical portion proved to be very difficult 
on account of the very long cervix. With the gradual loosening up 
of the uterus we found strong suggestions of adenomyoma. The 
uterus was accordingly amputated through the cervix and at once 
opened. The diagnosis of adenomyoma was immediately confirmed. 
In this case complete removal of the uterus would have entailed 
much painstaking dissection and would have prolonged the operation 
in the case of a vers'^ anaemic woman. 



186 



CHAPTER XII 
PROGNOSIS IN CASES OF ADENOMYOMA OF THE UTERUS 

When considering these growths in 1896, I agreed with von 
Reckhnghausen that they are benign.^ The glands are perfectly 
normal uterine glands and are surrounded by the normal stroma of 
the mucosa. They are confined entirely to the new growth and 
do not show the slightest tendency to invade the normal muscle. 
Wherever possible, it is always well to back up the impressions gained 
from histological study by the clinical sequence. And in two of 
our cases this has been unconsciously and yet admirably done. In 
Case 3600, on opening the abdomen, a diffuse myomatous thicken- 
ing was found in the posterior uterine wall. It was considered to 
be only a myomatous thickening, and a wedge-shaped piece of the 
growth was removed; in other words, a partial myomectomy was 
performed (Fig. 54). 

The histological picture as seen in Fig. 55 shows that the growth 
was a typical and diffuse adenomyoma of the uterus. The patient 
made a good recovery, and eleven years afterward, in response to 
an inquiry as to her condition, said that she had been greatly bene- 
fited by the operation and that she was in perfect health. The mass 
was certainly not entirely removed, and the subsequent history con- 
firms what was indicated by the histological findings, namely, the 
benign character of the growth. 

In Case 4415 we were also dealing with a diffuse myomatous 
uterine growth. A wedge, 5 by 2 cm., was removed through the 
abdomen. This patient also recovered. On examination the growth 
proved to be an adenomyoma. Here, also, notwithstanding the 
fact that portions of the growth were left behind, the patient was 

* Von Recklinghausen, Friedrich: Die Adenomyome und Cystadenome der 
Uterus und Tubenwandung; ihre Abkunft von Resten des Wolff 'schen Korpers, 
Berlin, 1896. 

187 



188 



ADENOMYOMA OF THE UTERUS 



much improved. For two years she had no trouble, but since then 
the periods have been longer, and sometimes last for weeks. She has, 
however, been completely relieved of pain at the menstrual periods. 

We see, therefore, from the his- 
tological and clinical pictures that 
these growths are benign. 

Since these two cases were pub- 
lished^ we have had several similar 
instances under observation. 




CASES GRAPHICALLY ILLUSTRATING 
THE BENIGN CHARACTER OF 
ADENOMYOMATA OF THE UTERUS 

Gyn. No. 3600. Path. No. 777. 
Diffuse adenomyoma 
of the posterior uter- 
ine wall (Figs. 54 and 55). 
Removal of a wedge- 
shaped portion of the 
growth. Complete re- 
lief from former symp- 
toms. 

G. H. W., married, white, aged 
twenty-five. Admitted June 24; 
discharged July 20, 1895. The 
patient has been married ten 
years, but has never been pregnant. Her menses began at 
thirteen, were regular and always associated with severe pain, 
dull and grinding in character, with sharp paroxysms referred 
to the abdomen and in the back. This pain has been growing 
much worse recently and has been associated with nausea. It 
is only present during the periods. The flow is very profuse 
and is growing more so. It is occasionally clotted. The patient 
has a slight leucorrhoeal discharge. 

* Cullen, Thomas S.: Adenomyome des Uterus, Berlin, 1903. 



Fig. 54. — A portion of a diffuse adeno- 
myoma OF THE posterior WALL OF THE 

UTERUS. (Slightly enlarged.) 

Gyn. -Path. No. 777. At opera- 
tion the posterior uterine wall was found 
much thickened. A wedge was removed and 
the cut surfaces were brought together as in 
an ordinary myomectomy, a is the peri- 
toneal surface; just beneath it is a narrow 
zone of normal muscle. The growth presents 
the typical appearance of a diffuse myoma. 
Along the outer margin it gradually merges 
into the normal muscle. ' b corresponds to 
the point nearest the uterine cavity. The 
uterine cavity was not opened. Scattered 
throughout the myoma are small round oval 
or oblong spaces. Some are dilated glands, 
others cross-sections of small blood-vessels. 
For the histological findings see Fig. 55. At 
the time the operation was performed we 
were unfamiliar with these adenomyomatous 
growths. 



PROGNOSIS 189 

Two months ago she noticed that the abdomen was larger than 
normal. 

Operation, June 26, 1895. Myomectomy. A myo- 
matous thickening was noted in the posterior wall. This thickening 
extended from the cervix to the fundus, and the uterus was the size 
of that of a three months' pregnancy. A wedge-shaped piece was 






'^•^ 



tif-'^iiif? 







s 






"^■\_ 



^. 






:^ 



-^^■' 



u 



■:,£«< 



d 
Fig. 55. — Diffuse adenomyoma. (6 diameters.) 

Gyn.-Path. No. 111. The section is taken from Fig. 54. The growth under the 
higher power was recognized as a diffuse myoma. At a and a' we find groups of glands resembling 
uterine glands both in form and in their even distribution. They are embedded in a definite 
stroma which separates them from the muscle. Some of the glands in the islands of mucosa show 
slight branching. At c the glands are arranged in "goose march" fashion. They are in all prob- 
ability sections of one and the same gland which has been much convoluted. At d one of the 
glands is moderately dilated, e shows a more marked dilatation, and here so much tension has 
taken place that little of the surrounding stroma remains. / corresponds very well to a miniature 
uterine cavity. On the one side it has become flattened out so that there is merely a layer of 
epithelial cells and a faint amount of stroma. On the opposite side is a well developed mucosa. 
Isolated glands are scattered throughout the growth. Without exception they are surrounded by 
the characteristic stroma and nearly all closely resemble uterine glands. The cystic dilatation is 
to be expected where the glands are subjected to the myomatous pressure. 

excised from the posterior wall and the uterine walls were brought 
together. The length of the incision in the uterus was 8 cm. The 
patient made a satisfactory recovery. 

January, 1907. The patient is perfectly well eleven years after 
operation. 

Gyn. Path. No. 777 . — The specimen consists of sev- 



190 ADENOMYOMA OF THE UTERUS 

eral large and small pieces of tumor. All of the tissue is pinkish- 
white in color, firm on pressure, and apparently composed of coarse 
fibres arranged in interlacing bundles (Fig. 54). 

Histological Examination . — The tissue consists of 
non-striped muscle fibres cut in various directions. Scattered here 
and there throughout it are glands occurring singly or in groups 
(Fig. 55). They are lined with high cylindrical ciliated epithelium 
and are surrounded by a stroma identical with that of the uterine 
mucosa. These glands are precisely similar to uterine glands. Some 
of them are dilated. 

Diagnosis . — Adenomyoma uteri diffusum benignum. 

Gyn. No. 4415. Path. No. 1207. 

Removal of a wedge-shaped piece of an 
adenomyoma of the posterior uterine wall. 
Complete cessation of the previous symp- 
toms for two years, followed again by pro- 
fuse menstruation. 

I. C. R., white, married, aged forty. Admitted May 28; dis- 
charged July 11, 1896. The patient has been married eighteen 
years and has never been pregnant. The menses commenced at 
twelve and were regular up to two or three years ago. Since that 
time they have occurred every twenty-second or twenty-third day 
The flow is profuse, dark and clotted, and associated with bearing- 
down pains in the abdomen and also with backache and pains in 
the legs. Micturition is frequent and the patient has a constant 
feeling of pressure on the bladder. The bowels are constipated. She 
suffers but little discomfort except at her menstrual periods. For 
the past year she has noticed a slight increase in the abdominal 
girth. 

Operation, June 1, 1896. Myomectomy. A wedge- 
shaped piece of the diffusely thickened wall was removed; also a 
pedunculated and partly cystic myoma, 5 by 2 cm. Convalescence 
was interrupted by an attack of phlebitis and one of pleurisy. The 
pleurisy developed at the base of the left lung and persisted for nine 



PROGNOSIS 191 

days. The phlebitis developed in the femoral vein on the twenty- 
second day. The patient made a satisfactory recovery. 

She remained well for two years and then again began to have 
profuse menstruation. 

Gyn. Path. No. 1207 . — The specimen consists of a 
subperitoneal myoma and several fragments of an interstitial 
myoma. 

The subperitoneal myomatous nodule measures 5 by 5 by 4.5 cm. ; 
it is pinkish in color and on pressure is firm. Springing from its 
surface is a cyst 2.5 cm. in diameter. This is whitish in color, its 
walls are semi-transparent, and it contains clear yellow fluid. On 
section the nodule presents the typical myomatous appearance. The 
walls of the cyst average 3 mm. in thickness and are rather soft. 
The inner surface on one side is smooth; on the other, roughened. 
The cyst appears to be a portion of the myoma that has undergone 
degeneration. The tumor also contains another area of degeneration 
measuring 2.5 by 1 cm. 

The fragments of the interstitial myoma are nine in number and 
the largest measures 4 by 3 by 1.5 cm. All of them are composed of 
bundles of coarse fibres forming an irregular network, in the meshes 
of which are minute cystic areas. One of these pieces is covered 
with peritoneum and the outer covering of normal muscle at that point 
is 4 mm. in thickness. The line of junction between the myomatous 
tissue and the normal muscle is sharply defined, but it is impossible 
to shell the tumor out at any point. 

Histological Examination . — The subperitoneal 
nodule is composed of non-striped muscle fibres, which in places have 
undergone moderate hyaline degeneration, at other points complete 
hyaline transformation. The line of demarcation between the in- 
tact muscle fibres and the degenerated portions is abrupt. 

The interstitial myomatous tissue is also composed of inter- 
lacing bundles of smooth muscle, but shows very little tendency 
toward hyaline degeneration. Scattered between the muscle bundles 
almost to the peritoneal covering are groups of glands or single gland- 
like spaces. 



192 ADENOMYOMA OF THE UTERUS 

These glands are small and round and sometimes send off one or 
more branches; some are dilated, reaching 1 to 2 mm. in diameter. 
They are lined with cylindrical epithelium, having oval vesicular 
nuclei situated in the centres of the cells. Surrounding the glands 
and separating them from the muscle is a moderate amount of 
stroma consisting of oval or elongate cells having oval vesicular 
nuclei. These cells are identical with the stroma cells of the uterine 
mucosa and the glands are in every respect similar to those of the 
uterus. The myomatous tissue has a moderately abundant blood- 
supply. 

Diagnosis . — Subperitoneal myoma. Interstitial adeno- 
mvoma of the uterus. 



CHAPTER XIII 
ORIGIN OF ADENOMYOMATA OF THE UTERUS 

In 1896 von Recklinghausen reviewed the Hterature of adeno- 
myomata and added many new cases. After a careful consideration 
of all, he concluded that in the vast majority of instances the glandu- 
lar elements were derivatives of the Wolffian duct. This opinion was 
based upon the supposed close analogy between the elements of the 
Wolffian duct and the glandular structures present in adenomyomata 
of the uterus. In only one case was he certain that the glands were 
due to down-growths of the uterine mucosa. This case of von Reck- 
linghausen was included in the appendix to his most instructive 
treatise. Since his publication appeared, much attention has been 
devoted to this subject and quite a number of new cases have been 
reported. Many writers have espoused von Recklinghausen's theory, 
but not a few have claimed that nearly all, if not all, of these cases 
owe their origin to the uterine mucosa or to a portion of Mtiller's 
duct. It would be unnecessary for us to review at length this lively 
controversy, but to those wishing the full details we would recom- 
mend the careful presentation of the subject as given by von Reck- 
linghausen,^ Meyer,^ Pick,^ and Kossmann.^ 

In my previous publication^ I reported nineteen cases of diffuse 
adenomyoma and pointed out that in the majority of these cases the 
process was still limited to the uterus, thus enabling us to determine 
definitely the origin of the glands in most of the cases. Since then 

^ Von Recklinghausen, Friedrich: Die Adenomyome und Cystadenome der 
Uterus- und Tubenwandung; ihre Abkunft von Resten des Wolff 'sc hen Korpers. 
Berlin, 1896. 

^ Meyer: Ueber Driisen, Cysten und Adenome im Myometrium bei Erwachsenen. 
Ztschr. f. Geb. u. Gyn., 1900, Bd. xlvii, S. 618; xlviii, S. 130 u. 329. 

' Pick: Archiv. fiir Gyn., IM. liv. 

* Kossmann, B. : Die Abstammung der Driiseneinschliisse in den Adenomyomen 
des Uterus und der Tuben. Arch. f. Gynaek., Bd. liv, 8. 359. 

^ CuUen, Thomas S.: Adeno-Myoma des Uterus, Berlin, 1903. 
13 193 



194 ADENOMYOMA OF THE UTERUS 

we have subjected each myomatous uterus to the most careful scru- 
tiny, and wherever adenomyoma was suspected we have had very 
large sections made from many parts of the uterine cavity. If adeno- 
myoma was present and no connection between the glands in the 
depth and the uterine mucosa could be detected, we kept on cutting 
more tissue, until finally in the vast majority of the cases we found 
that the gland elements were derivatives of the uterine mucosa. I 
have been greatly helped in this work by Mr. Benjamin O. McCleary, 
our laboratory assistant. 

We have had fifty uncomplicated cases of diffuse adenomyoma 
of the uterus, some very extensive, others in their early stages. In 
every one of these cases we have been able by persistent search to 
trace the uterine mucosa into the myomatous tissue. In other words, 
islands of mucosa in the diffuse myomata originated from the mu- 
cosa lining the uterine cavity in every case. Any one can verify 
this statement for himself by studying the pathological description 
in each case. 

In six other cases there was squamous-cell carcinoma of the 
cervix and diffuse adenomyoma of the body. In five of the six cases 
the origin of the gland elements in the myoma could be traced to the 
mucosa. In one case (Gyn. 9971), where the process was a rather 
indefinite one, it was impossible to show the origin of the glands from 
the mucosa. 

We thus see that in fifty-five out of fifty-six cases of diffuse adeno- 
myoma of the body of the uterus the gland elements were shown to 
be derived in part at least from the uterine mucosa. 

In Gyn. 8438 and also in Sanitarium No. 1852 diffuse adenomyoma 
of the body and adenocarcinoma of the body were present. In both 
of these the uterine mucosa has been destroyed, and the carcinoma- 
tous growth so overshadowed the picture that the origin of the glands 
in the myomatous growth was naturally totally obscured. 

SUBPERITONEAL ADENOMYOMATA 

In eight cases we have found subperitoneal adenomyomata. In 
Case 8647 there was a large subperitoneal adenomyoma, and exami-' 



ORIGIN OF ADENOMYOMATA OF THE UTERUS 195 

nation of the uterine mucosa showed that the glands extended 1.5 mm. 
into the muscle. Of course, no continuity with the subperitoneal 
nodule could be traced. In Case 3293 subperitoneal cysts of an 
adenomyomatous type were found, but in this case the uterine mucosa 
was normal. In Sanitarium No. 1872, in which the most typical 
adenomyoma lay perfectly free from the uterus, being attached to the 
utero-ovarian ligament (Fig. 41), the uterine mucosa extended into 
the muscle and the uterus was also the seat of discrete myomatous 
nodules. In Gyn. 5782 the adenomyomatous nodule was small and 
the uterine mucosa had been completely destroyed by the adeno- 
carcinoma. In the remaining case of subperitoneal adenomyoma the 
nodule alone was removed, and we had no chance to examine the 
uterine mucosa to determine if any continuity with the adenomyoma 
persisted. 1 

SUBMUCOUS ADENOMYOMATA 

We have had seven cases of submucous adenomyomata. Some 
consisted of diffuse myomatous growths containing only a few small 
glands. In others the glands had become cystic; in one case the 
myoma was riddled with miniature uterine cavities. In this case 
the direct continuity with the uterine mucosa was readily established. 

Where the uterine glands are seen penetrating the myomatous 
muscle, as in Figs. 2, 3, 6, 15, and 30, there is no question as to their 
being derivatives of the uterine mucosa, and, as will be seen from a 
study of our cases, in the majority of which the uterus was removed, 
the mucous-membrane origin was established. This fact is verv 
significant when compared with the figures of those claiming the 
Wolffian duct origin. With the increase in thickness and the ir- 
regular growth of the diffuse myoma it is very natural that the con- 
tinuity of the uterine glands into the depth should be lost after a 
time, as is evidenced by the formation of cysts. It is not necessary 
that the uterine glands be traced by continuity to establish the mucous- 
membrane origin. The islands of glands lying deep down in the 
myomatous muscle correspond identically with those seen in cases in 



196 ADENOMYOMA OF THE UTERUS 

which the continuity is traceable, and moreover they are precisely 
the same as in normal uterine mucosa. Furthermore, they are sur- 
rounded by a stroma identical with that surrounding the uterine 
glands. In some cases miniature uterine cavities are scattered 
throughout the myoma. Fig. 22, taken from a cavity near the peri- 
toneal surface of an adenomyoma, could not be distinguished from 
normal uterine mucosa. From the uterine mucosa there is a periodic 
hemorrhage every month. According to Hartz,* Sanger, when speak- 
ing to his students of the uterine mucosa, said : " This is no simple 
mucous membrane, but is an organ which has an important function 
to fulfil." With Sanger's view I am in thorough accord. In no 
other part of the body do we find a mucosa with a similar function, 
and nowhere else do we meet with such histological peculiarities. 
Now, if portions of this uterine mucosa be far removed from the 
parent mucosa, we should still expect them to retain their function, 
and this they do. In nearly every instance in which cyst spaces are 
present, the cavities are, in part or almost completely, filled with 
blood; and even in the small and undilated glands blood is fre- 
quently present, or the epithelial cells contain blood pigment, the 
remnants of old hemorrhages. It is natural that the cysts in the 
uterine walls should remain small, as they are compressed by the 
muscle; on the other hand, when they have once become subperi- 
toneal they may dilate until they can contain several litres of blood, 
although even in these cases they still show the evidence of the 
menstrual phenomenon as seen in their chocolate-colored contents. 
In the solid portions of these growths islands of t3^pical uterine mu- 
cosa are still demonstrable. It is so easy to understand how inter- 
stitial myomata become subperitoneal or submucous, and yet in 
considering the subsequent history^ of adenomyoma the majority of 
authors have forgotten to apply the same principle. When the 
growth becomes subperitoneal, we should expect its glandular ele- 
ments to gradually lose their continuity with those of the mucosa, 
and such is the case. Hence the confusion as to their origin. Case 

^ Hartz, A. L.: Neuere Arbeiten ueber die mesonephrischen Geschwiilste. Mon- 
atsschrift f. Geburtshlilfe und ( '.ynaekologie, 1901, Bd. xiii, S. 95 u. 244 



ORIGIN OF ADENOMYOMATA OF THE UTERUS 197 

2 of Breus' and Kroenig's case' illustrate very well the intraligament- 
ary variety. In Kroenig's case we have all the elements of normal 
uterine mucosa, and also large cysts. In Breus' case we find the 
same, but fortunatety the communication between the uterine 
mucosa and the cystic tumor still persists, showing beyond doubt 
that the gland elements in this case were from the uterine mucosa. 

A definite example of a portion of a diffuse adenomyoma becom- 
ing subperitoneal is furnished by Lockstaedt.^ The adenomyoma 
occupied the posterior wall and right side, and in the gross specimen 
it was possible, in at least five places, to see the mucosa extending 
deeply into the myoma. In this case there was a subperitoneal 
adenomyoma, the size of a cherry, that by its pedicle was in direct 
communication with the diffuse growth, so that its glands were un- 
doubtedly derivatives of those of the uterine mucosa. 

Were we in need of still further proof that these islands of mucosa 
are identical with normal uterine mucosa the case reported by J. 
Whitridge Williams' would certainly tend to convince the most 
skeptical. In examining the uterus of a patient entering the hos- 
pital in a desperate condition and dying two hours after labor he 
found that it was the seat of a diffuse adenomyoma and that the 
stroma of these islands had been converted into typical decidua. 

A somewhat similar decidual formation is reported on page 247. 
In this case I found a subperitoneal myoma near the right uterine 
horn. On the left side was an unruptured tubal pregnancy. The 
stroma of the adenomyoma had been in part converted into decidual 
cells, although the adenomyoma was at least 9 cm. away from the 
tubal pregnancy. 

^ Breus, Carl: Ueber wahre epithelfi'ihrende Cystenbildung in Uterus-Myomen. 
Leipzig und Wien, 1894. 

^ Kroenig, B. : Ein Retroperitoneal gelegenes voluminoses Polycystom entstanden 
aus Resten des Wolff'schen Korpers. Beitrage zur Geb. u. Gyn., 1901, Bd. iv, S. 61. 

^Lockstaedt: Ueber Vorkommen und Bedeutung von Driisenschlauchen in den 
Myomen des Uterus. Monatschr. f. (Jeb. u. (iyn., 1898, Bd. vii, 8. 188. 

* Williams, J. Whitridge: Decidual Formation Throughout the Uterine Muscu- 
laris: A Contribution to the Origin of Adenomyoma of the Uterus. Transactions 
of the Southern Surgical Association, 1904, vol. xvii. 



198 ADENOMYOMA OF THE UTERUS 

RESUME 

In the examination of fifty uncomplicated diffuse adenomyomata 
of the uterus the mucous-membrane origin of the glands could be 
traced in every case. In six additional cases where squamous-cell 
carcinoma of the cervix complicated adenomyoma of the body the 
continuity was established in five cases. In the two remaining cases 
of diffuse adenomyoma of the body the clue as to the origin of the 
glands was destroyed by the presence of adenocarcinoma of the body. 
Thus in only one case out of fifty-six in which we expected to find 
the glands originating from the mucosa, if our view as expressed in 
1896 was correct, did we fail to find it substantiated. In the re- 
maining fifteen cases of subperitoneal or submucous adenomyomata 
we would naturally not expect to trace the relationship between the 
mucosa and the glands in the myoma ; nevertheless in one case, Gyn. 
No. 10,314, the mucosa had literally flowed into the myoma. It will 
thus be seen that when we include adenomyomata of every kind, 
out of subperitoneal, submucous, or diffuse, we have been able in 
fifty-six out of seventy-three cases to trace the origin of the gland 
elements to the uterine mucosa. 

All adenomyomata of the uterus in which the gland elements are 
similar to those of the uterine mucosa, and are surrounded by stroma 
characteristic of that surrounding the normal uterine glands, owe 
their glandular origin to the uterine mucosa or to Miiller's duct, no 
matter whether they be interstitial, subperitoneal, or intraligament- 
ary, whether solid or cystic.^ 

* Frequently there are small cyst-like spaces apparently just beneath the per- 
itoneal surface of the uterus. These are lined with a single layer of cuboid al cells 
and rest directly on the muscle. They are due to depressions from the peritoneal 
surface, but at another level. In favorable sections their continuity with the per- 
itoneal cavity can be traced. Meyer has recently pointed them out. We thoroughly 
agree with his findings, and have also often met with them on the under or protected 
side of tubal adhesions or lining the small depressions occurring on the surface of 
the ovary. The peritoneal cells, where protected, tend to become cuboidal. 



CHAPTER XIV 
CAUSES OF ADENOMYOMA OF THE UTERUS 

We thought that possibly pregnancy with its incident extensive 
stretching of the uterus might leave crevices into which the mucosa 
could later flow. A reference to page 174, however, shows that 
fifteen out of forty-nine patients had never been pregnant, so that 
even were this a possible cause we must find another solution for 
those cases in which the adenomyoma had developed in a uterus that 
had never been subjected to the stretching incident to pregnancy. 
From a study of the clinical history we gain no clue as to the causation. 

Histological examination in a number of cases gives a decided 
impression that the diffuse myomatous growth is the primary factor. 
In these cases there is a myomatous tendenc}^, as evidenced by the 
almost constant presence of discrete ntyomatous nodules. The 
uterine mucosa flows into the chinks of the diffuse myomatous 
growth. As has been pointed out so frequently, the surface of the 
mucosa is perfectl}^ regular and intact and the uterine glands are in 
no wise altered. The only pathological change, in such cases, lies 
in the extension of normal glands into the crevices throughout the 
myomatous growth. 



199 



CHAPTER XV 

HYPERTROPHY OF THE CERVIX AND DIFFUSE ADENOMYOMA OF 
THE BODY OF THE UTERUS 

In the examination of thousands of specimens this is the most 
unique we have ever encountered. There is a marked increase 
in the size of the cervix due to simple hypertrophy, while the fundus 
has kept pace by the development of an adenomyoma. We ac- 
cordingly have a uterus which, although greatly enlarged, still has 
retained its relatively normal proportions. 

Gyn. No. 6240. Path. No. 2532. 

Very extensive h^^pertrophy of the cervix; 
diffuse adenomyoma of the anterior and poste- 
rior uterine walls (Fig. 56) with glands origin- 
ating from the uterine mucosa. 

L. C, aged fifty-two, married, white. Admitted July 15, 1898 ; dis- 
charged September 20, 1898. Complaint: Prolapsus of the uterus 
and uterine hemorrhage; pain in the abdomen. Her menses began 
at sixteen and were profuse, occurring ever}^ three weeks and lasting 
from seven to eight days. They have been irregular for the last two 
years and have been more profuse, the bleeding assuming the pro- 
portions of a hemorrhage. There has been a leucorrhcea and pro- 
fuse vaginal discharge for many years. The patient has had nine 
children, the eldest thirty years, the youngest fourteen. On examina- 
tion a large tumor is found projecting through the outlet — apparently 

Fig. 56. — Veky extensive hypertrophy of the cervix, discrete myoma and diffuse 

ADENOMYOMA OF THE BODY OF THE UTERUS. (Natural size.) 

Gyn. -Path. No. 2 532. We have purposely had the specimen drawn the natural size 
so that an accurate idea of the great and almost uniform increase in size of this organ is obtained. 
The cervix shows a very extensive hypertrophy, but is everywhere intact. A few of the cervical 
glands are dilated. At the fundus the subperitoneal myoma is seen. The uterine walls show 
considerable diffuse myomatous thickening, and scattered throughout them are seen islands of 
typical uterine mucosa. The continuity between them and the parent mucosa has in places been 
traced. 

200 



ASSOCIATED HYPERTROPHY OF CERVIX 



201 




Fig. 56. 



202 ADENOMYOMA OF THE UTERUS 

a complete prolapsus. The cervix is very prominent, 7 cm. in diam- 
eter and apparently ulcerated. 

Operation . — Vaginal hysterectomy; repair of perineum. 

Path. No. 2532 . — The specimen consists of the uterus, 
tubes and ovaries intact. The uterus is exceedingly long, being 
16 cm. in length, 7 cm. in breadth, and 4 cm. in its antero- 
posterior diameters (Fig. 56). It is free from adhesions. The pos- 
terior surface presents a more or less even appearance, while the 
anterior surface is round and shows a nodular mass just beneath the 
attachment of the left tube. The great length of the 
uterus is due to hypertroph}^ of the cervix, 
as the cervical portion is fully 8 cm. long. 
The outer portion of the cervix is rough and nodular and everywhere 
covered with mucosa. The mucosa lining the cervix is gathered up 
into folds. The mucous membrane of the body of the uterus in some 
places reaches 3 mm. in thickness. Both uterine walls present a 
coarse myomatous striation. 

Histological Examination . — The hypertrophy of 
the cervix is confined chiefly to the over-growth of the stroma. 
The surface epithelium is ever}' where intact. The papillae are in 
places long and branching and the overlying epithelium shows more 
hornification than usual. 

Sections from the anterior wall show that the mucous membrane 
is normal, but slightly thicker than usual. The wall is com- 
posed of diffuse myomatous tissue and scat- 
tered throughout it are typical islands of 
uterine mucosa. In a few places direct con- 
tinuity from the mucosa into the depth can 
be traced. The posterior wall also shows normal uterine 
mucosa with some thickening. Here there is likewise a diffuse 
adenomyoma. The islands of mucosa throughout the myoma 
closely resemble normal mucosa. In many places extension of the 
mucosa into the depth can be traced. 

Diagnosis . — Very extensive hypertrophy of the cervix ; 
diffuse adenomyoma of both the anterior and posterior uterine walls. 



CHAPTER XVI 

ADENOMYOMA IN ONE HORN OF A BICORNATE UTERUS 

It is interesting to find one horn of a bicornate uterus the seat of 
an adenomyoma. Whether the opposite horn was hkewise involved 
we cannot say, as the uterus was not removed. From a dinical 
standpoint it is also instructive, as in this case there was absolutely 
no connection between the vagina and the uterine cavity, there 
being practically no cervix. The condition in this case absolutely 
excludes any possibility that pregnancy has necessarily any causal 
relation to the development of the adenomyoma. 

Gyn. No. 10,516. Path No. 6764. 

Early adenomyoma in the left rudimentary 
horn of a bicornate uterus (Fig. 57), the glands 
coming from the uterine mucosa. 

V. P., black, aged twenty-four, married. Admitted May 27, 
1903; discharged June 25, 1903. Complaint: Absence of menstrua- 
tion. The menses did not commence until she was twenty-one. 
Then there was just a slight stain once, and none since. There 
has been severe pain in the left side and back every month for the past 
nine years. She was married at twenty -one, but has had no children. 
On ether examination a normal vagina was found extending in- 
ward for 5 cm., but no apparent opening could be made out between 
the vagina and the pelvic organs above. Bimanual examination 
of the left side showed a uterus apparently larger than normal. The 
cervix was separated from the vagina by a distance of at least 1 or 2 
cm. and apparently was not connected with it by adhesions or any 
bands of tissue. The cervix projected to the left. 

Operation, June 4, 1903. An attempt was made to 
form a new cervical canal, but this was given up because no connec- 
tion could be made out between the cervix and body, and also 

203 



204 ADENOMYOMA OF THE UTERUS 

because the external os was not patulous. Through the abdominal 
incision the following conditions were made out : On the left side was 
a small rudimentar}- uterus, 3 by 1.5 cm. There was no cervix and 
the organ was directly connected with a band of tissue, the latter in 
turn being connected with the cervix on the right side. Above the 
uterus was a large flattened tube with a normal fimbriated extremity 
and a normal ovaiy. On the right side the uterus was well developed 
and a little larger than normal. The cervix was poorly formed and 
had no external opening. The tube on this side had a normal fim- 
briated end and the ovary was normal. There were a number of 



x-^ / ^-^^ ^ i) P \ 




.-- V«g. \ 

Fig. 57. — Adexomyoma ix oxe horx of a bicornate uterus. (J natural size.) 

Gyn.-Path. 6764. The left horn, which was removed, is sketched, but the right 
horn is merely outlined. In this case there was no trace of any connection between either uterine 
horn and the vagina. 

adhesions to the upper part of the fundus and to the ovar}^, and 
several cysts containing clear fluid. Owing to the condition of the 
cornu on the left side, it and its appendages were removed. The 
patient made an uninterrupted recovery. 

Path. No. 6764 .—The globular body of the uterus 
is 5 cm. in diameter and covered w4th adhesions (Fig. 57). 
To it is attached a small left tube 5 cm. long, apparently normal, and 
an ovar>^ measuring 3 by 2 by 1 cm. The lower third of the body 
of the uterus contains no uterine cavity. In the upper third is seen 
a cavity 1 cm. long. The lining mucosa apparently shows no change. 



ADENOMYOMA IN ONE CORNU OF A BICORNATE UTERUS 205 

On histological examination the uterine mucosa 
is found considerably thickened and the skein-like arrangement of 
the glands is particularly well marked. Scattered every- 
where throughout the uterine wall, particu- 
larly abundant in the vicinity of the mucosa, 
are islands of uterine mucosa. These sometimes 
consist of large areas of mucous membrane and sometimes of a single 
gland surrounded by stroma and often much dilated. The muscle 
shows just the faintest tendency toward myomatous transformation. 
This is more evident macroscopically than microscopically. With 
the naked eye the uterine mucosa can be 
traced directly into the depth in places fora 
distance of 3 mm. We have here a diffuse adenomyoma in 
which the glands play the major role. It is particularly interesting to 
find an adenomyoma in one half of a bicornate uterus. The histological 
picture in this case would lead one to infer that the glands first existed 
and that the myomatous change was a secondary phenomenon. 
This is the first case that has suggested this origin to us. 



CHAPTER XVII ■ 

DIFFUSE ADENOMYOMA OF THE BODY OF THE UTERUS OCCURRING 
IN CASES OF SQUAMOUS-CELL CARCINOMA OF THE CERVIX 

Since the appearance in 1903 of a previous communication/ in 
which I reported a case of squamous-cell carcinoma of the cervix 
associated with diffuse adenomyoma of the body of the uterus, I 
have examined five similar cases. The simultaneous occurrence of 
both these processes in six cases in the records of one laboratory 
certainly indicates that the coexistence of these two diseases is no 
rarity. When we see what a large number of adenomj^omata have 
been detected when the uteri are carefully and systematically ex- 
amined, and knowing how wide-spread is squamous-cell carcinoma 
of the cervix, it is little wonder that these two processes are fre- 
quently found in the same uterus. The symptoms of the carcinoma 
of the cervix would naturally completely overshadow those of the 
adenomyoma. Consequently the marked extension of the uterine 
glands into the depth would not be suspected until after removal 
of the uterus. 

Gyn. No. 12,918. Path. No. 9841. 

Squamous-cell carcinoma of the cervix; 
diffuse adenomyoma of the uterine walls with 
direct extension of the uterine mucosa into 
the depth (Fig. 58). 

H. G., married, aged forty-two, black. Admitted May 9, 1906; 
discharged June 2, 1906. The patient has been married twenty-four 
years and has had four children, the oldest nineteen, the youngest 
fifteen. The clinical history is of little importance, as the symptoms 
of the carcinoma of the cervix and adenomyoma of the body merge 
so imperceptibly one into the other. 

^ Cullen, Thomas S.: Adenomyome des Uterus, Berlin, 1903. 

206 



ASSOCIATED SQUAMOUS-CELL CARCINOMA OF CERVIX 



207 



Operation . — Pan-hYsterectom3^ The entire growth was 
apparently not removed. The appendages were adherent to the 






*\>% .^ 



,^ ? «^^% 



d— 



t^ 



% 











^ "^v^^^ 



^-"c 



■tf^r/-' 



4>;- 



'^^' ^-r^' 



Fig. 58. — Diffuse adeno.myoma in the body of the uterus. (6 diameters.) 

Gyn.-Path. 9841. The section is from the upper part of the uterus, a indicates the 
uterine cavity and b and b' the normal thickness of the mucosa. The surface epithelium is intact 
and the glands are of the normal appearance, but the mucosa is everywhere flowing into the under- 
lying myomatous muscle, as is particularly well seen at c, d, and e. Sections at another level would 
show that the apparently isolated islands / and g are also continuous with the mucosa lining the 
uterine cavity. 

posterior surface of the uterus and were enlarged. The patient made 
a very satisfactory recovery. Her highest post-operative tempera- 
ture was 101.8° F. 



208 ADENOMYOMA OF THE UTERUS 

Path. No. 9841 . — The specimen consists of the uterus 
entire. It is 10 cm. in length. The cervical portion presents a 
worm-eaten appearance and this growth apparently extends to the 
cut surface anteriorly. Upward the growth can be traced as far as 
the internal os. In the body of the uterus the muscle varies from 
2 to 2.5 cm. in thickness. On making an examination through the 
right cornu we find that the inner zone of muscle over an area 2.5 cm. 
in diameter presents a diffuse myomatous thickening. There is an 
area covered by muscle 6 mm. in thickness. Exactly the same con- 
dition is noted on the left side, except that the myomatous muscle 
extends almost entirely through the wall. The uterine walls are 
covered, both anteriorly and posteriorly, with dense adhesions. 
The tube on the right side is involved in adhesions and is the seat of 
a hydrosalpinx. On the left side we have a typical follicular 
hydrosalpinx. 

Histological examination was made of sections 
embracing the uterine cavity and the anterior and posterior walls. 

Even with the dissecting microscope a most complete idea of the 
condition is obtainable. The surface epithelium is intact, the glands 
are normal, and the mucosa is seen penetrating the muscle in all 
directions. Nearly everywhere in the depth one 
is able to trace the continuity of the islands 
of mucosa with that lining the uterine cav- 
ity (Fig. 58). In the depth we have large areas of uterine 
mucosa, some of them 5 mm. in thickness. Occasionally some of 
these deep-seated uterine glands are dilated. At one point in the 
depth is a miniature uterine cavity, 9 mm. in length, varying from 
2 to 3 mm. in diameter. It is lined with one layer of epithelium 
which has taken up a great deal of blood pigment. Beneath this is 
a zone of stroma separating it from the muscle. The cavity is filled 
with blood — the remains of the former menstrual flow. The inner 
layers of the uterine muscle show diffuse myomatous transformation. 

We have here a squamous-cell carcinoma of the cervix, diffuse 
adenomyoma of the anterior and of the posterior uterine wall, with 
the gland elements originating from the mucosa. 



ASSOCIATED SQUAMOUS-CELL CARCINOMA OF CERVIX 



209 



Gyn. No. 9971. Path. No. 
6150. 

Squamous-cell 
carcinoma of the 
cervix (Fig. 59) ; 
diffuse adeno- 
myoma of the 
body of the uter- 
u s . 

A. S., married, aged 
forty, white. Admitted 
October 8, 1902; dis- 
charged November 12, 
1902. Complaint: Uter- 
ine hemorrhage and a 
watery discharge. The 
patient has been married 
twenty-four years and 
has had four children; 
the oldest twenty-three, 
the youngest seventeen. 



Fig. 59. — Squamous-cell carcin- 
oma of the cervix; discrete, 
subperitoneal and inter- 
STITIAL MYOMATA; DIFFUSE 
ADENOMYOMA OF THE POSTE- 
RIOR UTERINE WALL. (Natural 
size.) 

Gyn. No. 9971. Gyn.- 
Path. No. 6150. The lower 
picture represents the cervix with 
a small cuff of vaginal mucosa .sur- 
rounding it. The cervix presents 
a roughened and slightly nodular 
appearance due to the carcinoma. 
From the upper picture we see that 
the growth has invaded the cervix 
to a considerable extent. Situated in the fundus are two discrete myomata. The posterior wall 
shows diffuse myomatous thickening and at several points, indicated by o, discrete myomata 
are scattered throughout the diffusely thickened myomatous tissue. Histological examination 
shows islands of mucosa .scattered abundantly tliroughout the diffuse myoma. 
14 




210 ADENOMYOMA OF THE UTERUS 

The labors were normal. The patient was well until May of this 
year, when she had a slight hemorrhage and later noticed a slight 
serous discharge, which was irritating. 

Operation . — On examination of the cervix so strong 
was the suspicion of carcinoma that a complete hysterectomy was 
done. The appendages were adherent to the posterior surface of 
the uterus and the cervix was released with a great deal of difficulty. 
After operation there was excessive nausea and fecal vomiting for 
several days. For the first ten days the patient's life hung in the 
balance, but later on convalescence was rapid. The highest post- 
operative temperature was 100° F., on the second day. 

Path. No. 6150 . — The specimen consists of a myoma- 
tous uterus which has been removed entire. The myoma devel- 
oping in the anterior wall is 4 cm. in diameter. Below this and 
posterior to it is a similar one. The uterus is 12 cm. long and 6.5 
cm. broad. The anterior lip is denser than the posterior and suggests 
a new growth. On careful examination both lips are seen to present 
a finely granular appearance (Fig. 59). The uterine cavit}'^ measures 
3.3 cm. in length. The posterior uterine wall is 
fully 3 cm. in thickness and presents a fine 
diffuse myomatous appearance. 

On histological examination the cervix is found 
to be the seat of a squamous-cell carcinoma. This has not been 
entirely removed. Sections from the posterior wall of the uterus 
show that it is everj^where infiltrated with irregular islands of 
uterine mucosa. The tissue is made up of diffuse myomata. In 
the anterior wall there is a thickening of the uterine mucosa, but it 
is normal. In the examination of many sections only at one point 
is noted a slight tendency for the mucosa to extend into the depth, 
and one cannot with any degree of certainty say that there is a 
direct continuity with the glands in the endometrium. 

We are here dealing with squamous-cell carcinoma of the cervix, 
interstitial myomata, and diffuse adenomyonia of the posterior wall. 



ASSOCIATED SQUAMOUS-CELL CARCINOMA OF CERVIX 211 

C. H. I. No. 511. Path. No. 8426. 

S q u a m o u s - c e 1 1 carcinoma of the cervix; 
diffuse adenomyoma of the body with the 
gland elements coming from the mucosa. 

E. J. R., married, aged sixty, white. Admitted March 21, 1905; 
died March 24, 1905. Complaint: Uterine hemorrhages and pain. 
(The patient had a definite squamous-cell carcinoma of the cervix 
which obscured the other symptoms.) The patient has had ten 
children, the eldest thirty-six, the youngest ten years; no mis- 
carriages. In September, 1904, she was paralyzed on the right side. 
It was three months before she regained complete control over her 
right hand. 

Operation . — Complete hysterectomy was performed. The 
patient did well for the first day, was restless on the second day. 
There was complete suppression of urine, although the ureters had 
been carefully dissected out and had been found to be in no way 
obstructed. She soon became cyanosed and there was muscle 
twitching; she died on the second day after operation. 

Path. No. 8426 . — The specimen consists of the uterus and 
of a part of the vagina; also of the tubes and ovaries. The cervix 
is the seat of an extensive carcinoma which involves the posterior 
lip and a portion of the vagina. There are also some nodules in the 
vagina. Posteriorly the growth apparently extends to the line of 
incision and out into the left parametrium. The body of the uterus 
looks normal. 

On histological examination the cervix pre- 
sents a far advanced squamous-cell carcinoma. 

The chief interest is centered in the endometrium. The uterine 
walls are atrophic, and with the low power one can see ver\^ large 
blood-vessels in the outer layers. These show beginning oblitera- 
tive changes. The muscle of the uterine wall is exceedingly dense 
and looks myomatous. The endometrium isatrophic, 
but at several points we can trace it extend- 
ing a long distance into the depth. We have 
here a mild grade of adenomyoma. 



212 ADENOMYOMA OF THE UTERUS 

Diagnosis . — Squamous-cell carcinoma of the cervix ; 
moderate diffuse adenomyomatous formation in the body of the 
uterus. 

Gyn. No. 12,060. Path. No. 8602. 

Squamous-cell carcinoma of the cervix; 
diffuse adenomyoma of the body of the uterus 
with the glands originating from the mucosa. 

L. N., married, aged fifty-six, white. Admitted April 18, 1905; 
discharged j\Iay 21, 1905. The patient has had four children, the 
youngest fourteen years old. The menopause occurred two years 
ago. 

Operation . — Panhysterectomy. As the growth was far 
advanced the operation was fraught with much difficulty. The 
highest post-operative temperature was 101.4° F. The patient 
made a satisfactory recovery. 

Path. No. 8602 . — The specimen consists of the uterus, 
which is almost normal in size, and of the appendages. The uterus 
with the enlarged cervix is 9 cm. in length, 6 cm. in breadth, and 4 
cm. in its antero-posterior diameters. Anteriorly it is smooth and 
glistening. Posteriorly it is almost free from adhesions. The cervix 
has been converted into a crater-like cavity approximately 5 cm. in 
diameter. The outer vaginal portions of the cervix are normal, but 
posteriorly and anteriorly it is wanting, the tissue presenting an 
eaten-out wormy appearance. Anteriorly the growth extends almost 
to the cut surface. On section, macroscopically the growth can be 
traced for at least 1 cm. into the underlying tissue. The uterine 
muscle shows little or no thickening, but the inner layers 
are somewhat coarser than usual. The mucosa 
varies from 1 to 2 mm. in thickness. 

Histological examination shows a typical squa- 
mous-cell carcinoma of the cervix with a good deal of small round- 
cell infiltration along the margins. The cervical glands are con- 
siderably dilated and the stroma in the cervical portion has not quite 
the ordinary appearance and somewhat resembles muscle. 



ASSOCIATED SQUAMOUS-CELL CARCINOMA OF CERVIX 213 

Sections from the mucosa show that the surface epitheUum is in 
places intact; at many points, however, it has been mechanically 
removed. The glands are normal in size, but at other points are 
dilated, and the cell protoplasm is undergoing disintegration. At 
some points we have isolated glands penetrating the muscle and 
extending into the depth in funnel-shaped forms. In other 
places two or three glands can be traced for 
at least 4 mm. into the underlying tissue. 
This extension into the depth is noted at several points, and in the 
underlying muscle are islands of perfectly normal mucosa. The 
muscle surrounding the uterine cavity is denser than usual and is 
undergoing a diffuse myomatous transformation. The muscle in 
the outlying portion is fairly normal. We have here an adeno- 
myoma in which the gland elements are derived from the uterine 
mucosa. 

Diagnosis . — Primary squamous-cell carcinoma of the cer- 
vix; diffuse adenomyoma of the body of the uterus. 

Gyn. No. 12,304. Path No. 8890. 

Squamous-cell carcinoma of the cervix. 
The chief interest lies in the adenomyoma 
of the body. 

L. S., aged fifty, white. Operation, August 18, 1905. Pan- 
hysterectomy. 

Sections from the endometrium show that the mucosa can 
be in places traced for at leasts or 4 mm. 
into the underlying muscle. It shows a typical 
myomatous picture. We have here a diffuse adenomyoma with 
carcinoma of the cervix. 

Gyn. No. 3126. Path. No. 493. 

Squamous-cell carcinoma of the cervix (Fig. 
60) . Adenomyoma of the body of the uterus. 

L. E. H., white, aged fifty-six, a widow. Admitted October 21, 
1894; discharged November 25, 1894. The patient entered the 



214 ADENOMYOMA OF THE UTERUS 

hospital complaining of pain in the rectum and lower part of the back. 
She had had some hemorrhage. Two paternal aunts had died of 
phthisis, and her mother of cancer of the uterus at forty-nine years 
of age. Her paternal grandmother was also supposed to have died 
of cancer of the uterus. 

Menstrual History . — The periods commenced at six- 
teen; they were always regular, but painful during the first few 
years. She suffered from membranous dysmenorrhcea. For the 
last ten years there has been an offensive odor at the menstrual period. 
The menopause occurred at fifty-three. She had had several chil- 
dren. 

Present Illness . — For five or six years before the 
menopause, which occurred three years ago, the patient suffered 
with irregular and severe hemorrhages from the uterus. From the 
time of the menopause no hemorrhages occurred, but the patient 
complained of nervousness. In July of this year she noticed a 
yellowish vaginal discharge. In August she complained of pain in 
the lower abdomen and of some swelling in the legs. 

In July and August the desire to urinate was constant. These 
symptoms have subsided since then. The bowels are markedly 
constipated and defecation is accompanied by hemorrhage. There 
is, however, no tingeing of the stools with blood. 

The patient is very ansemic and nervous, but there is no marked 
emaciation. 

Operation . — The carcinoma of the cervix was curetted 
away as far as possible with the finger. After thorough cleansing 
of the uterus the vagina was incised, an area around the margin of 
about 1 cm. of normal mucosa being loosened up with the cervix. 
An abscess between the uterus and rectum was then opened and 
about 2 c.c. of creamy pus escaped. The vaginal edges were brought 
together so that the diseased area of the cervix was completely walled 
off. The abdomen was then opened and the uterus removed from 
above. Considerable difficulty was experienced, however, on ac- 
count of the extension of the growth to the broad ligament. The 
patient made a good recovery and was discharged on November 



ASSOCIATED SQUAMOUS-CELL CARCINOMA OF CERVIX 



215 



25th. The nervous symptoms were, however, prominent. Re- 
appearance of the growth was noted and the patient died sixty days 
after operation, apparently of exhaustion. 

Gyn.-Path. No. 493 . — The specimen consists of the 




A B 

Fig. 60. — Commencing diffuse adenomyoma of the body of the uterus associated 

WITH ADVANCED SQUAMOUS-CELL CARCINOMA OF THE CERVIX. (y% natural size.) 

Gyn.-Path. No. 493. A, The lower part of the cervix and surrounding portions 
of the vaginal vault are replaced by a new growth having a shaggy surface due to myriads of finger- 
like outgrowths. Laterally this growth extends practically to the broad ligament attachment; 
upward its confines are indicated by the letters a, a. The upper part of the cervix and body 
seem little altered. At 6 is a small polyp. The mucosa in the upper part of the cervix and in 
the body is very thin but smooth. B, a longitudinal section of A. The extent of the growth in 
the posterior wall is clearly outlined at a. The cystic cervical polyp is seen at c. The posterior 
w'all is made up of two distinct portions, an outer consisting of normal muscle and an inner pre- 
senting a diffuse myomatous appearance. This coarse tissue extentls directly to the mucosa. 
At d is a small discrete myomatous nodule. From the text it will be noted that the uterine 
walls show a commencing myomatous transformation and that the glands in many places pene- 
trate the muscle for a distance of 9 mm. 



uterus with its appendages intact. The uterus measures 8 by 6 
by 3 cm. and both anteriorly and posteriorly is smooth and glisten- 
ing. Occupying the outer portion of the cervix, both anteriorly 
and posteriorly, is a worm-eaten and in part papillary-like surface 
(Fig. 60). In the latter portion the little elevations are found to 



216 ADENOMYOMA OF THE UTERUS 

consist of small finger-like or knob-shaped processes, some of which 
apparently branch. Anteriorly the growth extends out to the vagina, 
while posteriorly it involves the vault for at least 1.5 cm. On section 
it is found that only the outer portion of the cervix is implicated and 
that the cervical mucosa for a distance of 2.5 cm. is still intact. 
Several of the cervical glands are dilated, and projecting into the 
canal is a small polyp. The uterine cavity is 3 cm. long. Its mu- 
cosa, which appears to be less than a millimetre in thickness, is smooth 
and ghstening. Situated on the left side of the cavity is a pale 
bluish-white polyp 1 cm. long, 1.2 cm. broad, 4 mm. thick. The 
tubes and ovaries present their usual appearance. 

Histological Examination . — The worm-eaten cer- 
vix shows considerable necrosis of its surface. The underlying 
tissue is everywhere infiltrated by masses of cells having a finger-like 
or branching arrangement. Some of these have been cut across and 
appear as circular nests. Scattered throughout the alveoli are 
numerous areas in which the cell protoplasm stains intensely with 
eosin. The concentric arrangement of the cells is suggestive of 
epithelial pearls. The new growth appears to extend nearly to the 
margin of the incision. Whether or not it has been entirely removed, 
it is impossible to say. The tissue surrounding the alveoli shows 
marked small round-cell infiltration along the advancing margin of 
the growth. 

The cervical glands, just within the external os, are normal, but 
as one approaches the internal os many of them are dilated. The 
uterine mucosa near the internal os and also that throughout the 
cavity shows considerable dilatation of its glands and scattered 
throughout the stroma are numerous small round cells. Pene- 
trating the muscle in man 3^ places to a depth 
of 9 mm. are bunches of ver}^ small glands, which 
are separated from each other and also from the muscle by the usual 
amount of stroma. They are abnormal dippings-down of the mu- 
cosa, which do not, however, show the least sign of malignancy. 
The uterine wall shows some hyaline degeneration. The muscle 
tends to become myomatous and in one place contains a myoma 4 



ASSOCIATED SQUAMOUS-CELL CARCINOMA OF CERVIX 217 

mm. in diameter. The uterine polyp consists of mucosa and 
a few of its glands are dilated. The appendages are practically 
normal. 

Diagnosis. — Squamous-cell carcinoma of the cervix; ex- 
tension of the uterine glands into the muscular walls, which show 
a tendency to become myomatous; small interstitial myoma; nor- 
mal appendages. 



CHAPTER XVIII 

ADENOCARCINOMA AND ADENOMYOMA OCCURRING INDEPENDENTLY 
IN THE BODY OF THE SAME UTERUS 

The following case is interesting on account of the fact that an 
adenocarcinoma of the body of the uterus and a small but typical 
subperitoneal adenomyoma are associated in the same uterus. Of 
course, the one is in no way dependent on the other. 

Gyn. No. 5782. Path. No. 2084. 

Adenocarcinoma of the body of the ut- 
erus (Fig. 61); small myoma in the anterior 
wall; small adenomyoma in the posterior 
wall; hysterectomy. 

M. K., aged fifty-six, admitted January 12, 1898, complaining 
of pain in the lower abdomen. The menses were irregular, oc- 
curring at intervals of from two to six weeks. They were very 
painful and lasted from three to seven days. They ceased four 
years ago. About a year and a half ago a bloody discharge was 
noticed which at times was clotted. During the last six months 
it has been frequent, but at no time has it been offensive. The 
patient has been married twenty-one years. She has had one 
child and no miscarriages. She has never been strong, and during 
the past year has had severe pain in the lower abdomen extending 
down the legs. At present the bowels are constipated. On Jan- 
uar^^ 12th the cervix was dilated and a small amount of tissue was 
removed for examination. The uterus was slightly enlarged but 
freely movable. Two nodules could be seen on the posterior sur- 
face. 

Gyn. -Path. No. 2075 . — The specimen consists of a con- 
siderable amount of curettings. The tissue is composed of small 
pieces which do not present the smooth glistening surface of normal 

218 



ADENOCARCINOMA AND ADENOMYOMA IN THE SAME UTERUS 219 



Adeno 'Carcinoma. 



Adeno'- 
tTtyom^j 



mucosa. They are finely granular or show minute, papillary-like 
out-growths. On histological 
examination adenocarcinoma 
of the body of the uterus was 
found and hysterectomy was 
advised. The uterus was re- 
moved in the usual way. The 
patient made a good recovery 
and was discharged February 
15, 1898. 

Gyn.-Path. No. 
2 8 4 . — The specimen con- 
sists of the uterus with the 
appendages. The uterus is 
8 cm. in length, 5.5 cm. in 
breadth, and 5 cm. in its an- 
tero-posterior diameter. Its 
surface is deep red in color 
and free from adhesions, but 
projecting from the posterior 
portion is a small, firm nodule 
1.2 cm. in diameter (Fig. 61). 
The outer surface of this no- 
dule is covered with a calcar- 
eous plate 2 mm. in thickness. 
On section the growth is found 
to be continuous with the 
uterine muscle, with which it 
is intimately associated, the 
sharp line of demarcation so 
characteristic of myomata be- 
ing wanting. The calcareous 
deposit has extended into the 
nodule at one point. The cervical canal is 3 cm. in length. Its 
mucosa is finely granular and slightly injected. The uterine cavity 




Fig. 61. — Adenocakcinoma of the body of the 
uterus associated with a small subperi- 
TONEAL ADENOMYOMA. (Natural size.) 

Gyn.-Path. No. 2 084. The uterus 
is of normal size. The left half appears in the 
figure. Attached to the posterior surface near the 
fundus is a small subperitoneal myoma, which on 
histological examination is found to contain mu- 
cosa resembling that of the uterus. In the middle 
of the anterior wall is a small interstitial myoma; 
the cervix is intact. The mucosa in the lower 
part of the cervical canal is normal, but that of 
the body is replaced by a new growth. The inner 
surface presents an eaten-out appearance due to 
the finger-like growths. The growth itself is light 
in color and appears to be friable. It does not 
seem to penetrate the uterine walls very far, but 
as the subsequent history showed the case was one 
of the most malignant we have encountered. It 
is rather interesting to find a myoma, an adeno- 
myoma and an adenocarcinoma of the body of 
the uterus in the same patient. 



220 ADENOMYOMA OF THE UTERUS 

is 5 cm. long and 4 cm. in breadth at the fundus. The mucosa in 
the lower portion of the cavity is roughened and granular. On 
passing further upward it is found to be thicker and more furrowed. 
The upper half of the cavity is occupied by a new growth consisting 
of papillary' masses varjdng from 1 to 6 mm. in size. These tree- 
like growths consist of delicate papillae which often show secondary 
branching. Some of the papillae are glistening, some are translucent; 
others are yellowish and opaque, while not a few are deeply injected. 
The growth has extended for 8 to 10 mm. into the uterine muscle. 
The deeper portions consist of a fibrillated waxy material, which 
is sharply differentiated from the surrounding muscle. The growth 
penetrates the muscle more deeply on the left side. Downward 
it reaches to within 1 cm. of the internal os. 

The appendages are senile, but present nothing of importance. 

Histological Examination . — The vaginal portion 
of the cervix is practically normal. The folds of the mucosa lining 
the cervical canal present the usual appearance. The surface epithe- 
lium is to a great extent intact and the underlying glands are normal. 
Sections from the bod}^ of the uterus show that the greater part of 
its cavity is occupied by a neoplasm. Along the advancing margin 
this appears in the form of irregularly branching outgrowths, con- 
sisting of delicate stems of stroma covered by one or more layers 
of cylindrical epithelium. On passing toward the older portions of 
the growth this papillary— like arrangement becomes more complex. 
In the deeper portions the glandular arrangement is more in evidence, 
and along the advancing margin where the growth has penetrated 
the muscle, large bunches of glands are seen. The gland-like ar- 
rangement in many places is perfectly preserved and the epithelial 
cells are remarkably uniform in size. In some places the stroma is 
fairly abundant, but at other points it is only just sufficient to sup- 
port the delicate blood-vessels. The preservation of the glands, 
which show^ practically no coagulation necrosis, is rather remarkable, 
and is more probably due to their slight deviation from the normal 
than to any increase in blood-supply, since the latter is by no means 



ADENOCARCINOMA AND ADENOMYOMA IN THE SAME UTERUS 221 

abundant. Along the advancing margin of the growth the muscle 
shows small round-cell infiltration. 

The small nodule situated on the posterior uterine wall consists 
of non-striped muscle fibres cut in various directions. The blood- 
vessels are few in number and frequently show obliteration. At 
a few points 2 or 3 mm. beneath the peritoneal covering are deeply 
staining areas, at first sight suggesting small round-cell infiltration, 
were it not for the fact that they are too sharply circumscribed and 
that with the higher powers it is impossible to distinguish them from 
the stroma cells of the uterine mucosa. Some of these areas contain 
glands irregular or elongate in form and lined with one layer of low 
cylindrical epithelium on which cilia can sometimes be demonstrated. 
Some of the gland cavities contain desquamated epithelium; others 
enclose a varying amount of blood. The nodule is a myoma. The 
glands and their surrounding stroma resemble more or less the uter- 
ine mucosa. We are dealing with a small sub- 
peritoneal adenomyoma. Sections from the tubes 
show nothing abnormal. Both ovaries contain a few small gland- 
like spaces, but are otherwise normal. 

Diagnosis . — Adenocarcinoma of the body of the uterus, 
associated with a subperitoneal adenomyoma and an interstitial 
myoma. 



CHAPTER XIX 

ADENOCARCINOMA OF THE BODY OF THE UTERUS DEVELOPING 
FROM AN ADENOMYOMA 

From our consideration of adenomyomata of the uterus, it is 
seen that the gland elements are practically normal uterine glands 
in both their histological and physiological aspects. From normal 
uterine mucosa we often have developing an adenocarcinoma. Con- 
sequently we should not be surprised if an adenocarcinoma were 
sometimes detected in an adenomyoma. Von Recklinghausen in 
his entire series of adenomyomata found only two cases in which 
he thought there was a carcinomatous change. Meyer also had a 
suspicious case, but from his description we would hardly venture 
a positive diagnosis of malignancy. In Gyn.-Path. No. 4656, an 
instance of carcinoma of the body of the uterus, we noted several 
dark areas deep in the muscle. They consisted of typical islands 
of uterine glands surrounded by the stroma of the mucosa. Some 
of the glands were dilated, forming cyst-like cavities. In one of 
these cavities (Fig. 62), lined by a single layer of cylindrical epithe- 
lium and separated from the muscle by a definite stroma, the epi- 
thelium had proliferated, forming new glands and papillarv^ out- 
growths consisting almost entirely of solid masses of cancer cells. 
This case is undoubtedly one of adenocarcinoma developing in part 
from a cystic gland situated in the adenomyoma. 

In Sanitarium No. 1852 we found a similar condition. The 
body of the uterus was the seat of a typical adenocarcinoma and 
deep in the muscle areas of adenomyoma were found. At one point 
the carcinoma was seen developing from one of the glands in the 
adenomyoma. In this case the histological picture also strongly 
suggested the independent development of sarcoma of the body of 
the uterus. 

222 



ADENOCARCINOMA DEVELOPING FROM ADENOMYOMA 223 

CASES ILLUSTRATING THE DEVELOPMENT OF ADENOCARCINOMA OF THE 
BODY OF THE UTERUS FROM ADENOMYOMA 

Gyn. No. 8438. Path. No. 4656. 

Adenocarcinoma of the body of the uterus 
developing, in part at least, from the glands 
of an adenomyoma (Fig. 62). 

M. S., married, aged fifty-six, white. Admitted Januarj^ 9; 
discharged February 9, 1901. The patient entered complaining of 
uterine hemorrhages. The menses commenced at seventeen and 
were not painful. The menopause occurred at fifty-three. The 
patient has had five children, the eldest thirty-three years of age. 

One year after the menopause, i. e., two years ago, the patient 
noticed a slight uterine discharge, usually blood tinged. This has 
been a little more profuse of late and has contained some blood. 
She has neither pain nor discomfort and has lost no weight. The 
only symptom has been the uterine bleeding. 

January 19, 1905: Vaginal hysterectomy. The patient made a 
satisfactory recovery. 

Gyn. -Path. No. 4656 . — The specimen consists of the 
uterus, which is little, if at all, enlarged, measuring 8 by 6 by 4 
cm. The outer surface is smooth and the vaginal portion of the 
cervix presents the usual appearance. The cervical mucosa is in- 
jected but normal. In the uterine cavity nearly all trace of the 
normal mucosa has disappeared and we have finefinger-like 
processes or small polypoid masses, some reach- 
ing 1 cm. in length, springing from the surface. The deeper portions 
of this growth have invaded the muscle in the vicinity of the cornu 
for a distance of from 5 to 7 mm. The uterine walls are of the normal 
thickness, but at some points the tissue is coarser than usual and is 
somewhat suggestive of a diffuse myoma. 

Histological Examination . — The cervical mucosa 
is perfectly normal. Near the internal os the epithelial lining of the 
glands is altered. Some of the cells are quite regular and uniform. 
Others are swollen, have light-staining nuclei, and are several layers 
thick. High in the cavity the glands have proliferated and are 



224 



ADENOMYOMA. OF THE UTERUS 




Fig. 62. — Adenoc.\rcixoma developing from a dilated glaxd in an adenomyoma of the 

UTERUS. (45 diameters.) 

Gyn.-Path. No. 4656. Occupying the centre of the field is a large cystic space 
lined with one layer of cylindrical epithelium (a) and separated from the surrounding myomatous 
muscle (c) by a faint zone of characteristic stroma (6). In the upper part of the field numerous 
glands are seen opening into the large cavity. These glands are also lined with cylindrical epi- 
thelium. Projecting into the cavity are the four large folds d, d', d" and d'". These new folds 
have a stroma very rich in small round cells and are surrounded by many layers of epithelial 
cells. At points e, e, e the gland epithelium is seen to become swollen and greatly thickened and 
this thickened epithelium is directly continuous with that covering the folds. As is clearly evi- 
dent, the growth is an adenocarcinoma. In this case the carcinoma was seen developing from 
other similar areas as well as from the mucosa lining the uterine cavity. 



ADENOCARCINOMA DEVELOPING FROM ADENOMYOMA 225 

invading the muscle. The gland type, as a rule, is well preserved, 
but in some places the epithelium has so proliferated that the gland 
cavities are obliterated. Deep down in the muscle are groups of 
carcinomatous glands, which in places extend to within 1 cm. of 
the peritoneal surface. In some places there is a moderate infiltra- 
tion with polymorphonuclear leucocytes. In some portions of the 
uterus the muscle fibres stain more deeply than usual and show a 
tendency to become myomatous. Here the tissue suggests a diffuse 
myoma. Scattered throughout it are isolated islands of uterine 
mucosa consisting of the characteristic glands with their surround- 
ing stroma. At several points these glands are 
dilated, and in at least two places the gland 
epithelium has proliferated, forming new 
glands of an undoubted carcinomatous type. 
Fig. 62 illustrates a carcinoma developing from one of these cystic 
and dilated uterine glands. It shows conclusively that carcinoma 
may develop from the gland elements of an adenomyoma. This, 
however, is nothing more than we might expect, since the gland 
elements of adenomyomata are, as a rule, nothing more than normal 
uterine glands which have grown into the muscle. 

H. A. K. Sanitarium No. 1852. Path. No. 8347. 

Adenocarcinoma of the body of the uterus; 
diffuse adenomyoma with the glands becom- 
ing carcinomatous. Independent sarcoma of 
the body of the uterus. 

B. H. C, aged fifty -four, white, married. Admitted March 31, 
1905; discharged April 21, 1905 Operation: Panhysterectomy, 
colostomy and removal of vaginal implantation. 

The patient has been married twenty-seven years and has had 
four children but no miscarriages. The menopause occurred four 
years ago. For three months there has been a constant leucorrhoea 
with a bloody vaginal discharge. 

Operation, March 8th. Panhysterectomy. The patient 
did not improve well after operation, and finally on the fifth 

15 



226 ADENOMYOMA OF THE UTERUS 

day it was found necessary to bring out a loop of small intestine. 
This was fastened to the abdominal wall and was opened with a 
cauter}^ At a later date the patient became insane. She had a 
return of the growth in the vaginal wall. For this radium was used. 
Later she went to Dr. John McCoy, of Paterson, N. J., for a:-ray 
treatment. 

In May, 1905, her condition was much worse, and her physician 
removed a vaginal mass under cocaine. At the time he made a note 
that there was a tremendous amount of infiltration of the tissue 
between the vagina and rectum. Pathological examination of the 
vaginal specimen showed it to be a typical sarcoma. 

Path. No. 8347 . — The uterus is 10 cm. long, 8 cm. broad, 
and 6 cm. in its antero-posterior diameters. The cervix looks nor- 
mal. The uterine walls var}^ from 2 to 4 cm. in thickness. The 
increased thickening in the posterior wall is due to a new growth 
which projects into the cavity. The superficial half of this is blu- 
ish-black in color. The outlying portions are white and somewhat 
porous in appearance and sharply differentiated from the normal 
outer muscular covering. The appendages on both sides appear to 
be unaltered. 

Histological Examination . — Sections from the 
cervix show that the surface epithelium is the seat of chronic infil- 
tration, there being a marked round-cell infiltration, also potymor- 
phonuclear leucocytes, and the underljdng stroma is exceedingly 
vascular. Sections from the uterine mucosa show that there is in 
places loss of surface epithelium. In other places it is intact. 

The endometrium in the lower part of the body shows consider- 
able hemorrhage, evidently the result of curettage. The stroma is 
infiltrated with small round cells to a limited extent and the glands 
are seen projecting into the underlying muscle. Sections from the 
upper part of the body, where the growth is present, show that the 
surface of the growth is almost entirely necrotic and that this ne- 
crotic material contains quantities of potymorphonuclear leucocytes 
and blood. At other points in the necrotic material we have longi- 
tudinal sections of blood-vessels surrounded by many layers of cells 



ADENOCARCINOMA DEVELOPING FROM ADENOMYOMA 227 

having oval, deeply staining nuclei. Such areas suggest vety much 
an angiosarcoma. In other portions of the growth the cells are 
closely packed together; nevertheless with the low power it is possible 
to make out an indefinite glandular arrangement. In other words, 
down near the muscle we have a typical adenocarcinoma of the type 
so frequently found in the body, the skein-like arrangement of the 
glands and the papillary outgrowths, and all of these covered by 
one and sometimes several layers of epithelium. There are also 
numerous minute glands. The line of junction between the portion 
of the growth that looks sarcomatous and that which is distinctly 
cancerous is sharply outlined. Sections from other portions of the 
growth leave little doubt that we are dealing with a sarcoma, there 
being large fields with cells uniform in size and having very little 
stroma, just sufficient to carry the blood-vessels. Numerous nuclear 
figures are found scattered through this tissue. 

Another most interesting point in this connection is the presence 
of islands of normal glands in the depth. Some of these have sur- 
rounding stroma and present the typical appearance of adenomy- 
oma. Islands of mucosa are surrounded by myomatous tissue, and 
in one of these islands we have an adenocar- 
cinoma developing directly from the mucosa 
of one of the normal glands. One is able to 
trace the direct continuity from the epithe- 
lium in such an island into the carcinoma- 
tous tissue. The muscle external to the point of growth 
shows a good deal of small round-cell infiltration. 

We have here a subacute inflammation of the cervix, an adeno- 
carcinoma of the body of the uterus, and an adenomyoma of the 
body of the uterus. To a certain extent the adenocarcinoma is 
derived directly from islands of normal mucosa in the adenomyoma, 
but in part evidently from the uterine mucosa lining the cavity. 
There is an apparently independent round-cell sarcoma in the body 
of the uterus. Fortunately we are able to clinch the diagnosis 
absolutely, as the metastases which occurred subsequent to removal 
of the uterus showed typical sarcoma. 



CHAPTER XX 

A MULTIPLICITY OF PATHOLOGICAL CHANGES IN THE PELVIS 

(a) Subperitoneal myoma. 
(h) Adenomyoma. 

(c) Primary adenocarcinoma of the body of the uterus. 

(d) Pyosalpinx. 

(e) Primary adenocarcinoma of the ovary. 



>PpLmary ade no - carcVn.o msL 




Fig. 63. — Myoma, adexomyoma and primary adenocarcinoma of the body op the uterus; 

PYOSALPINX AND PRIMARY ADENOCARCINOMA OF THE OVARY. (§ natural size.) 

Specimen sent by Dr. Joseph Price, of Philadelphia. Path. No. 9312. Occupying 
the body of the uterus is an adenocarcinoma. Isolated carcinomatous nodules are scattered 
throughout the muscular walls and at one point have nearly reached the peritoneal surface. On 
one side is a discrete myoma. On the other near the uterine horn a diffuse adenomyoma, which 
on histological examination presented the typical appearance. The tube is thickened in its outer 
portion and was filled with pus. The ovary has been converted into a porous growth, partly 
cystic and divided off into smaller areas by trabeculse. This carcinomatous growth was of a totally 
different pattern to that occupying the uterus. 

About two years ago I received a rather unpromising-looking 
specimen from my friend, Dr. Joseph Price, of Philadelphia. On 
careful examination, however, it was evident that it was a most 
unusual one. 

228 



MULTIPLE PATHOLOGICAL CHANGES IN PELVIS 229 

From Fig. 63 we see that the body of the uterus is extensively 
involved in an adenocarcinoma. On one side is a discrete myoma, 
while on the opposite side is an adenomyoma. One tube is markedly 
distended with pus and has been densely adherent, as is indicated 
by adhesions. One ovary is much enlarged and occupied by a new 
growth. 

Histological examination showed that the growth was a primary 
adenocarcinoma of a totally different type from that occupying the 
uterus. There were in this pelvis five distinctly independent patho- 
logical processes. 

We often make a very positive diagnosis before operation, only 
to find, when the abdomen is opened, a condition totally different 
from that we had expected. No surgeon could possibly have given 
an accurate diagnosis in such a case as this. From the contour one 
might readily have diagnosed a multinodular and adherent my- 
omatous uterus. The carcinoma could, of course, have been readily 
recognized upon examination of scrapings from the body. 



CHAPTER XXI 

DIFFUSE MYOMATOUS THICKENING OF THE UTERUS BUT NO 
GLANDULAR INVASION 

Whenever the uterus is the seat of diffuse myomatous thicken- 
ing, adenomyoma will immediately be suspected. On histological 
examination in the vast majority of cases, gland elements will be 
found scattered throughout the growth. There are a few cases, 
however, in which the diffuse growth exists and yet no invasion of 
glands has occurred. The following cases belong to this group. 
In Sanitarium No. 1847 there was also a suppurating submucous 
myoma. In Case No. 12,221 the increase in size of the uterus was 
due in part to a diffuse myomatous thickening, but chiefly to a recent 
pregnancy. Even in cutting the uterus open adenomyoma was 
suspected, and not until the histological examination showed no 
gland invasion, and decidual cells were demonstrated, was an exact 
diagnosis made. 

H. A. K. Sanitarium 1847. Path. No. 8346. 

Diffuse myomatous thickening of both the 
anterior and posterior uterine walls; break- 
ingdown of a submucous myoma with suppu- 
ration, producing in all probability a mild 
endometritis of the body and of the cervix; 
normal appendages on the left side; Graafian 
follicle cyst on the right. 

W. J., aged thirty -four, married. Admitted March 1, 1905; 
discharged April 12, 1905. The patient has been married eleven 
years, has had two children and no miscarriages. Labors normal. 
The menses have been irregular and profuse for the last year, oc- 
curring every three weeks. For the last two weeks she has noticed 
a vaginal discharge. The patient has a sallow appearance; the 

230 



DIFFUSE MYOMATOUS THICKENING OF THE UTERUS 231 

haemoglobin is 50 per cent. There was apparently a passage of a 
small tumor from the vagina a few weeks ago. Since then there 
have been chills and fever accompanied by a good deal of abdominal 
pain in the region of the ovaries. 

Path. Nos. 8346 and 8346 § .—The specimen con- 
sists of the uterus, about twice the natural size, the left normal tube 
and ovary, the right tube, and a cystic right ovary. The body of 
the uterus itself is 10 cm. in length, 9 cm. in breadth, and 8 cm. in 
its antero-posterior diameters. It is smooth and glistening. The 
thickening in the uterus is found to be due to a diffuse thickening 
in both the anterior and posterior walls. The anterior wall varies 
from 2 to 4.5 cm. in thickness; the posterior from 2 to 3 cm. in thick- 
ness; and projecting from the fundus into the cavity is a submu- 
cous myoma, 2.5 cm. in diameter. In the vicinity of this are hard 
areas rather difficult to explain. In the myoma there are areas of 
hyaline transformation. The uterine cavity itself is 6 cm. in length, 
the mucosa 1 mm. in thickness. At first it looks as if we had a dif- 
fuse adenomyomatous thickening of both the anterior and posterior 
walls, but at no point macroscopically is one able to trace the mucosa 
into the depth. The left tube and ovary are normal. The right 
tube is normal. The ovary is somewhat thickened and contains one 
cyst, approximately 4 cm. in diameter, and adjoining this is an oval 
cyst, 6 cm. in its longest diameter. The inner surfaces of these are 
perfectly smooth, and one would have soon merged into the other. 
They seem to be Graafian follicle cysts. 

Histological Examination . — The cervical glands 
are in places much dilated, and covering the surface of the cervix 
are here and there quantities of polymorphonuclear leucocytes which 
have come down from the body of the uterus. The stroma is to a 
slight extent infiltrated with small round cells. There is, however, 
very little infiltration of the cervix itself and the glands in the depth 
are perfectly normal. Sections from the body of the uterus show a 
submucous myoma, which to a great extent has been transformed 
into hyaline material. We have here and there spindle cells, chiefly 
fibrous in character, and in other places cells which have taken up 



232 ADENOMYOMA OF THE UTERUS 

yellowish-brown pigment, evidentty the remains of old hemorrhages. 
Here also we have thrombosed vessels. The surface of the myoma 
consists essentially of granulation tissue containing polymorphonu- 
clear leucocytes in its meshes, and covering the surface are fibrin 
and quantities of leucocytes. In this tissue are large and small 
blood-vessels. The majority of these are filled with fibrin and 
leucocytes. In other words, there has been coagulation necrosis. 
At no point do we find any evidence of glands in the depth. 

Sections from the larger cyst of the right ovary show that it is 
lined with cuboidal epithelium, the nuclei being situated in the 
middle of the cells. There is no doubt that the growth is a Graafian 
follicle cyst. 

Diagnosis .—Diffuse myomatous thickening of both the an- 
terior and posterior uterine walls; breaking down of a submucous 
myoma with suppuration, producing a mild endometritis. The 
appendix in this case shows chronic inflammation. 

Gyn. No. 12,221. Path. No. 8832. 

Thickening of a recently pregnant uterus 
which clinically gave symptoms simulating 
myoma. The uterus on removal was strongly 
suggestive of a diffuse adenomyomatous con- 
dition. 

L. D., aged thirty-seven, married, white. Admitted July 7, 
1905; discharged August 4, 1905. The diagnosis on admission was 
infected submucous myoma. The patient began to menstruate at 
fifteen, was regular until after the birth of her first child, but has been 
somewhat irregular since then. She has been married for eighteen 
years, and has had seven children and one miscarriage at the eighth 
week, a year and a half ago. She had some irregular bleeding several 
months ago. Five months ago she ceased bleeding, but the last two 
months she has been in bed. The periods recurred, appearing every 
two or three weeks. The hemorrhages were profuse. It is rather 
difficult to get the exact date of the last period. The patient has 
lost 9 pounds in the two weeks previous to her admission to the 



DIFFUSE THICKENING OF PREGNANT UTERUS 233 

hospital. Her haemoglobin is 62 per cent, and she presents a rather 
emaciated appearance. 

Operation . — Vaginal hysterectomy. The highest post- 
operative temperature was 100.2° F. She made a satisfactory re- 
covery. 

Path. No. 8832 .—The specimen consists of the uterus. 
It is 10 cm. in length, 7 cm. in breadth, and 6 cm. in its antero-pos- 
terior diameters. It is free from adhesions. The cervix looks nor- 
mal. The posterior uterine wall varies from 1 to 3.5 cm. in thickness 
and presents a coarse appearance. In the anterior wall the mucosa 
is 2 mm. in thickness, in the posterior it reaches 5.6 mm., where 
there is localized thickening. The general appearance is very sug- 
gestive of adenomyoma. 

On histological examination the cervix is found to present a 
rather suspicious appearance. We have an intact vaginal epithe- 
lium, then a proliferation of the cervical epithelium, the glands 
having formed many new and smaller ones. The proliferation in 
places is solid and here suggests squamous epithelium. At other 
points there is loss of the surface epithelium, and we have typical 
granulation tissue. There has evidently been an inflammation here, 
giving rise to the proliferation. The infiltration, however, is not 
wide-spread, as in the underlying stroma it is not extensive. In the 
body of the uterus the mucosa in places is intact and the glands look 
normal or are somewhat dilated. At other points the surface con- 
sists entirely of necrotic tissue or of canalized fibrin, and deeper still 
are small glands and a few decidual cells in the stroma. The blood- 
vessels in the mucosa show a marked change. The cells are swollen 
and are typical decidual cells. In the stroma there is a good deal 
of small round-cell infiltration and at a few points what appear to 
be villi, devoid to a great extent of their epithelial covering. For a 
short distance into the muscle we can trace glands, and deep in the 
muscle there are what appear to be decidual cells together with 
swollen muscle fibres. 

In this case, as seen from a clinical standpoint, the diagnosis of 
probable mj^oma of the body of the uterus was made. The uterus 



234 ADENOMYOMA OF THE UTERUS 

was enlarged and there was evidently uterine hemorrhage and a 
certain amount of discharge. Moreover, the menstrual history 
was not satisfactory. Even after the uterus had been removed the 
thickened wall strongly suggested adenomyoma, but, as we see on 
histological examination, there are typical evidences of pregnancy. 
There is no discrete myoma, although there is a definite tendency 
toward myomatous thickening. 



CHAPTER XXII 

ADENOMYOMATA OF THE UTERINE HORN 

Meyer has very justly divided these into two groups according 
to their situation and source of origin. The uterine mucosa is con- 
tinued up into the cornu, where it becomes very thin, there being 
merely the surface epithelium, a small amount of stroma of the 
mucosa, and a few glands. The mucosa becomes still thinner, and 
at the interstitial portion of the tube, which is within the uterine 
horn, gradually passes over into the tubal epithelium. This epithe- 
lium is identical in character with that lining the uterine cavity, but 
the peculiar stroma found in the uterine mucosa is entirely wanting 
and no glands are present. 

ADENOMYOMATA ARISING FROM THE UTERINE PORTION OF THE UTERINE 

HORN 

These consist of small diffuse thickenings of the uterine cornu. 
As a rule, they are not larger than 1 centimetre in diameter, but 
occasionally may reach the size of a walnut (Fig. 65, p. 243). They 
consist of gland-like spaces, usually cystic, and are surrounded by 
a difTuse myomatous muscle. The cysts are lined with cylindrical 
ciliated epithelium and contain desquamated epithelium and blood. 
Where the glands are much dilated, they may lie in direct contact 
with the myomatous muscle, but the smaller ones are separated from 
the muscle by the characteristic stroma of the mucosa. The myo- 
matous tissue seems to be circularly arranged around the gland 
spaces, and it frequently appears as if the myomatous thickening 
was due almost entirely to the irritation set up by the glands. These 
myomata may be near the tube lumen, in the vicinity of the peri- 
toneum or lie near the broad ligament. The origin of the gland ele- 
ments was referred by von Recklinghausen and others to the Wolf- 
fian duct, but in the last few years their continuity with the uterine 

235 



236 ADENOMYOMA OF THE UTERUS 

glands has been traced, and it is probable that the majority, if not 
all, of these adenomyomata owe their glandular elements to the 
uterine mucosa. The only difference between these and the diffuse 
growths in the uterine cavity is their small size and their relative 
poverty in gland elements. When we remember that the glands in 
the uterine horn are few and far between, this scanty glandular 
distribution is readily understood. 

ADENOMYOMATA FROM THE TUBAL PORTION OF THE UTERINE HORN 

These growths, likewise situated in the uterine horn, also con- 
sist of small myomata containing isolated gland-like spaces or small 
cysts. These spaces are lined with a single layer of cylindrical, 
ciliated epithelium. They may be situated in the inner muscular 
layers of the tube or penetrate nearly to the peritoneal surface on the 
one side, or to the mesosalpinx on the opposite side. They differ 
from those originating in the uterine portion of the uterine horn in 
that the epithelium rests directly on the muscle instead of being 
separated from it by the characteristic stroma (Fig. 64, p. 237). 
The reason for this was at first sight difficult to understand, but 
after von Franque,^ Meyer, ^ Gottschalk,^ and Lockstaedt^ had shown 
conclusively that the gland-like spaces were nothing more than pro- 
longations outward of the tubal mucosa, the solution w^as clear, as 
in the tubal mucosa the characteristic stroma of the uterine mucosa 
is wanting. The origin of the gland-like spaces in these growths 
was likewise formerly attributed to remains of the Wolffian body, 
but we now know that the majority of these represent prolonga- 
tions outward of the tubal mucosa, probably followed second- 
arily by the myomatous development, as is evidenced by the fact 

' Von Franque, O. : Salpingitis nodosa isthmica unci Adenomyoma Tubae. 
Centralbl. f. Gynaek., 1900, Bd. xxv, S. 660. 

^ ^leyer: Ztschr. f. Geburtshiilfe und Gynaekologie, Bd. xlii, H. 1. 

^Gottschalk: Demonstration zur Enstehung der Adenome des Tubenisthmus. 
Ztschr. f. Geburtshiilfe und Gynaekologie, 1900, Bd. xlii, S. 616. 

^ Ijockstaedt, Paul: Ueber Yorkommen und Bedeutung von Driisenschlauchen 
in Myomen des Uterus. Monatsschr. f. Geb. u. Gyn., 1898, Bd. vii, S. 188. 



ADENOMYOMATA OF THE UTERINE HORN 



237 



that these outgrowths are often found independent of the myo- 
matous growth. 

Chnically, these small myomata in the uterine horns are of 
little importance. They are not recognized until the organ has 
been removed for some other cause, usually myomata or pus tubes. 
For a period of over five years (1893-1898) we had sections taken 




..g-c^ 



^° 






% 



/? r 









I 



t^J^'^ 



43>5^^ 



^^- 



a 




'i 



'ii:xO 



:AmMm 



Fig. 64. — Adenomyoma of the uterine horn. (8 diameters.) 

Gyn.-Path. No. 4820. a is a cross-section of the Fallopian tube; h the outer or 
peritoneal surface; c the tissue near the broad ligament. Scattered everywhere throughout the 
tissue, which under a higher power was seen to be myomatous, are round, oval or irregular, 
elongate glands, occurring singly or in bunches. These were lined with cuboidal or cylindrical 
epithelium which in most places rested directly on the muscle. This appears to be an adeno- 
myoma originating from the tubal portion of the uterine horn. 

from both uterine horns as a routine procedure, and found groups 
of these gland-like spaces, with or without myomatous thickening, 
to be very common. 



CASES IN WHICH ADENOMYOMATA WERE DETECTED IN THE UTERINE HORN 

In this group we have not attempted to divide the cases into 
those originating from the uterine portion of the horn and those 
derived from the tubal portion, but have included them all in the 
same class. 



238 ADENOMYOMA OF THE UTERUS 

Gyn. No. 11,572. Path. No. 7800. 

Subperitoneal and interstitial uterine my- 
omata; adenomyoma of the left uterine horn; 
normal appendages. 

R. J. R., aged thirty-three, black, married. Admitted September 
27, 1904; discharged October 27, 1904. The patient has been mar- 
ried thirteen years, but has never been pregnant. 

Operation . — Hysterectomy. The patient made a satis- 
factor}^ recover\^ 

Path. No. 7800 . — The specimen consists of a greatly 
enlarged uterus and of the tubes and ovaries. The body of the 
uterus is normal in size, but springing from its surface are several 
small pedunculated myomata. In the left uterine horn is a distinct 
thickening, the nodule being 1.5 cm. in diameter. The tube lies 
perfectly free. Attached to the fundus by a pedicle, 2.5 cm. in 
diameter, is a large mj^omatous tumor, 20 by 15 by 10 cm. It is 
irregular and nodular. The tumor and the uterus are free from 
adhesions. The appendages are apparently normal. 

Sections from the nodule in the left horn show what appears to 
be the lumen of the tube surrounded by several definite glandular 
areas. Embedded in this stroma and scattered throughout the 
nodule is a diffuse myoma. There are gland spaces lying in direct 
contact with the muscle. These glands are lined with one layer of 
high cylindrical epithelium. They appear to have originated from 
the uterine portion of the tube, although it is impossible to state 
this with certainty. 

Diagnosis . — Subperitoneal and interstitial uterine m3^omata. 
Adenomyoma of the left uterine horn; normal appendages. 

Path. No. 3721. 
A small uterus with somewhat suspicious 
changes; adenomyoma of the left uterine 
horn; cystadenoma of the right ovary with 
carcinomatous changes; cystadenoma of the 
left ovary. 



ADENOMYOMATA OF THE UTERINE HORN 239 

The specimen consists of the uterus, both tubes, and a cyst on 
each side. The uterus is exceedingly small and as far as can be 
determined measures 4 cm. in length, 3 cm. in breadth and 1.4 cm. 
in thickness. The uterine walls are very soft and vary from 7 to 
9 mm. in thickness. The cavity is seen as a slit-like depression. 
It is 3 cm. in length. The mucous membrane is 2 mm. in thickness. 
The anterior and posterior surfaces of the uterus are smooth save 
for a few delicate adhesions. 

On histological examination the uterine mucosa shows marked 
senile atrophy. Its surface is smooth. The glands are moderate 
in amount and in some places are considerably dilated. The epithe- 
lium, as a whole, is lower than usual. The glands are flattened. 
Some are irregularly arranged and present little papillary growths. 
Immediately beneath the left cornu is a nodule. This is com- 
posed of myomatous tissue containing glands lined with a low columnar 
epithelium of uniform appearance. On the right side there is a 
cystadenoma, portions of which show carcinomatous changes. On 
the left side there is a simple cystadenoma. 

Diagnosis . — Small uterus with suspicious change ; adeno- 
myoma in the left uterine horn; cystadenoma of the right ovary 
with carcinomatous change; cystadenoma of the left ovary. 

Gyn. No. 6635. Path. No. 2845. 

Adenomyoma in the uterine horn with com- 
mencing subperitoneal adenomyoma. 

P., aged thirty, white. Operation, January 14, 1899. Sections 
from the uterine wall show that the mucosa reaches 5 mm. in thick- 
ness. An oblique section through the stump of the right tube shows 
a small lumen of the tube with irregular outlines, lined with normal, 
low, cylindrical, epithelial cells. Situated some distance from the 
tube, surrounded by a definite circular zone of muscle, is an island 
of mucosa, perfectly normal in character. This is surrounded in 
numerous places by irregular glands lined with cylindrical epithe- 
lium and filled with desquamated epithelium and old hemorrhage. 
We have here the foundation for a subperitoneal adenomyoma. 



240 ADENOMYOMA OF THE UTERUS 

Gyn. No. 3805. Path. No. 892. 

The tube at the uterine horn is re presented 
by three o-land spaces instead of a lumen. 

M. W., aged thirty-one. September 22, 1895. Pathological 
diagnosis: Right hydrosalpinx, left perisalpingitis, gland-like spaces 
in the uterine cornu. We have sections from the left uterine horn. 
The uterine horn is represented by three glands instead of a lumen, 
a very unusual picture. This is readily recognized, as we have the 
two definite layers of muscle surrounding them. We have here 
gland-like spaces which are irregular or round, some of them oblong. 
They are lined with cylindrical epithelium and characteristic stroma. 
This is the first case in which on examination of the uterine horn 
we have found the lumen represented by three distinct spaces. 

Gyn. No. 3715. Path. No. 843. 

Adenomyoma of the uterine horn. 

E. S., white. August 15, 1895. Diagnosis: Remnants of an 
old endometritis; commencing abscess in the right uterine cornu; 
gland-like spaces in the uterine cornu ; double perisalpingitis ; double 
perioophoritis. On examination of sections from the left uterine 
horn we find in the upper part a few small gland-like spaces a short 
distance beneath the peritoneum. These are round or oblong on 
cross-section and beneath the tube we also find some gland spaces. 
All the glands are lined with cylindrical epithelium. Some of them 
are rather complex, and instantly suggest an origin from a Wolffian 
duct; others resemble uterine mucosa. The tube lumen is much 
degenerated and is filled with pus. 

Gyn. No. 3395. Path. No. 649. 

Partial atrophy of the uterine mucosa; 
gland-like spaces in the uterine horn. Right 
side: chronic salpingitis, miliary abscess 
of the ovary. Left side: chronic salpingitis 
and perioophoritis. 

H., white. March 30, 1895. Sections from the uterine horn 



ADENOMYOMATA OF THE UTERINE HORN 241 

show numerous adhesions and some gland-hke spaces. These are 
small and round on cross-section. They are lined with cylindrical 
or cuboidal epithelium and are filled with desquamated epithelium. 
They lie in direct contact with the muscle. The tissue is evidently 
the seat of chronic inflammation, as is evidenced by the presence of 
many small round cells. Sections from the left tube show only one 
or two gland-like spaces and there is much less evidence of inflam- 
matory reaction. 

Gyn. No. 3401. Path. No. 647. 

Partial atrophy of the uterine mucosa, 
gland-like spaces in both uterine horns, ac- 
cessory ostium of the right tube, large simple 
hydrosalpinx of the left tube; slight ad- 
hesions on both sides. 

Examination of the uterine cornu with the low power is most 
confusing at first, and one is hardly able to recognize the cross- 
section of the tube. Surrounding the tube on all sides, but particu- 
larly between the tube and the peritoneum covering the surface, are 
colonies of glands. Covering one surface are numerous adhesions 
consisting chiefly of omentum. The gland-like spaces to a great 
extent communicate with one another, as is evidenced by the little 
bridges here and there. Some of the gland spaces lie almost beneath 
the peritoneum and seem to be foreign to the uterus. The majority, 
however, are in direct contact with it. They are lined with cuboidal 
or cylindrical epithelium. The picture is a most interesting one. 

On the left side sections from the cornu show a similar condition, 
although the picture is not so confusing. We are able to trace a 
definite channel which looks very much as if it were an outgrowth 
of the uterine mucosa. In this case we have a portion of adeno- 
myomatous tissue definitely cut off and forming an independent 
subperitoneal adenomyoma. In none of these do we find much 
evidence of stroma. 

16 



242 ADENOMYOMA OF THE UTERUS 

C. H. I. No. 15 17. Path. No. 10,669. 

Adenomyoma in both uterine horns (Fig. 65) ; 
diffuse adenomyoma of the uterus; minia- 
ture uterine cavity. 

S. E. W., married, aged forty-three. Admitted December 2, 
1906. The patient has not been well for the last five or six years. 
Her periods during this time have been profuse, at times lasting as 
long as twelve days. She has had no children and no miscarriages. 
She has had some retention of urine at times; at other times there 
is frequency of micturition. There has been leucorrhcea for five 
or six years. 

Operation . — Hystero-mj^omectomy and appendectomy. 
The patient made a satisfactory recovery. The highest post-opera- 
tive temperature was 101.6° F. 

Path. No. 10,669 . — The specimen consists of a multi- 
nodular, myomatous uterus, 10 cm. in length, 13 cm. in breadth, 
and 11 cm. in its antero-posterior diameters. The uterus is every- 
where smooth and glistening. The increase in size is due to sub- 
peritoneal, interstitial, and submucous myomata. The largest 
nodule, 8 cm. in diameter, is situated anteriorly and to the right. 
The uterine cavity is very small and is much distorted. In the 
left uterine horn is an area of thickening (Fig. 65). This is directly 
continuous with the tube and is 4 cm. in length, and varies from 1 to 
2.5 cm. in breadth. It appears to be cystic and on section presents 
a sieve-like or polypoid appearance. There are also irregular cystic 
spaces, varying from 1 to 5 mm. in diameter. At least seven or 
eight of these are seen in one cross-section. The right tube is 
occluded, and reaches 4 cm. in diameter. The ovary is slightly 
mutilated. The right tube at the uterine horn presents an area of 
thickening 1.5 cm. in diameter. On section this horn is also seen to 
contain cystic spaces, one of them at least 3 mm. in length. 

Histological Examination . — Sections taken from 
the right uterine horn show a most instructive picture. Cross- 
section of the tube shows that it is perfectly normal. Just to one 
side is a miniature uterine cavity lined with one laj^er of epithelium. 



ADENOMYOMATA OF THE UTERINE HORN 



243 



In other portions there are numerous uterine glands, the majority 
of which are dilated. Some lie in direct contact with the muscle. 
Others are separated from it by a small amount of stroma. A" most 
interesting picture is noted in some places, namely, that the bunches 
of uterine glands are surrounded b}^ a circular layer of myomatous 




Fig. 65. — Adenomyoma of both uterine horns; discrete myomata; diffuse adeno- 
MYOMA OF THE UTERUS, (f natural size.) 

C. H. I. No. 1517. Gyn.-Path. No. 10,669. Occupying the uterus are 
several myomatous nodules. The left tube is the seat of a hydrosalpinx; it is firmly fixed to the 
ovary and to the surface of the uterus. At the left uterine horn is a definite thickening. This area 
appeared cystic and on making an incision from a to a' the picture in B was found. The cyst 
spaces were irregular in form and varied from 1 to 5 mm. in diameter. A similar and smaller 
cystic tumor was present at the right uterine horn, as indicated by c. This on examination pre- 
sented the same picture as did that of the left. On histological examination the thickenings in 
both horns were found to be due to the presence of adenomyoma. The glands were of the uterine 
type and in many places were surrounded by the characteristic stroma of the mucosa. Near 
c was a typical miniature uterine cavity. The uterine walls were the seat of a diffuse adenomyoma. 



tissue. Riddling the mucosa everywhere at the uterine horn are 
uterine glands occurring singly or in bunches. Near the peritoneal 
surface, as noted macroscopically, some of the glands reach 2 mm. 
or more in diameter. The gland cavities in places contain desqua- 
mated epithelium and the epithelium has taken up blood-pigment 



244 ADENOMYOMA OF THE UTERUS 

and some polymorphonuclear leucocytes. The origin of these glands 
it is impossible to determine. 

Sections from the left uterine horn also show many cyst spaces, 
as noted macroscopically. Some of these reach 3 mm. or more in 
diameter. They may be circular, oval, or irregular in shape, and 
looking at the specimen macroscopically one sees islands of uterine 
mucosa surrounded by a definite and well-defined zone of muscle. 
With the low power we find the large cyst spaces lined with one 
layer of epithelium resting directly on the muscle. Such cyst 
spaces may be found beneath the peritoneum. At other points 
are colonies of glands, and in the depth we find typical islands of 
normal uterine mucosa, many of which are surrounded by the char- 
acteristic stroma. It is impossible to definitely determine the 
origin of these glands in the lower portion. The gland-like spaces 
are either empty or filled with desquamated epithelium and swollen 
cells that have taken up pigment. 

Diagnosis . — Adenomyoma in both right and left uter- 
ine horns. In this case the uterine mucosa has everywhere riddled 
the myomatous uterine walls. 

Gyn. No. 3399. Path. No. 645. 

Slight atrophy of the uterine mucosa; 
small interstitial uterine myomata; gland- 
like spaces in the uterine cornu. Small ab- 
scess in the cornu. Right side: chronic 
salpingitis; general adhesions. Left side: 
adhesions and a small cyst springing from 
the left ovary. 

The interest lies in the fact that only one tube is involved. 

B., aged twenty-four, colored. March 28, 1895. 

Sections from the right uterine cornu show with the low power 
several gland-like spaces between the cross-section of the tube and 
the peritoneal surface. They lie about 2 or 3 mm. from the lumen. 
The majority of them are irregular and are lined with cuboidal or 
cylindrical epithelium. One of these cysts in several places has 



ADENOMYOMATA OF THE UTERINE HORN 245 

stroma projecting into it. These are covered with somewhat flat- 
tened epithelium and the cavities contain a few polymorphonuclear 
leucocytes. There are also numerous other minute glands lined 
with cylindrical epithelium and lying in direct contact with the 
muscle. 

Gyn. No. 3379. Path. No. 633. 

The uterine mucosa is normal, but con- 
tains numerous lymphoid nodules; gland-like 
spaces in adhesions over the uterine cornu; 
gland-like spaces in the uterine cornu; gen- 
eral pelvic adhesions; a small cyst of the 
ovary, probably from a Graafian follicle. 

On examination of the right uterine horn the spaces are of little 
interest, but on the left side, where the section represents a field 
closer to the uterus, — in other words, where the tube is just begin- 
ning, — we have gland-like spaces practically just beneath the ad- 
hesions of the peritoneal surface. They are lined with cylindrical 
epithelium. A little beneath the peritoneum and running into 
the muscle is a similar gland space lined with a definite layer of 
cylindrical, ciliated epithelium and surrounded by a zone of 
lymphoid cells. Lying at the lower level, even with the tube, are 
irregular gland spaces lined with a similar epithelium and filled with 
blood, while still further down are irregular spaces which com- 
municate with one another and are likewise filled with blood. 
The latter bear a striking resemblance to those in the uterine 
mucosa, although they have no definite stroma surrounding them. 



CHAPTER XXIII 

PREGNANCY IN THE LEFT FALLOPIAN TUBE; DISCRETE UTERINE 

MYOMATA ; DIFFUSE ADENOMYOMA IN THE RIGHT UTERINE 

HORN WITH THE DEVELOPMENT OF DECIDUAL CELLS 

AROUND THE GLANDS IN THE ADENOMYOMA 

This case was particularly interesting from a clinical standpoint, 
as we were able to make a diagnosis of tubal pregnancy from the 
velvety feel of the tube.* From a histological and etiological point 
of view the transformation into decidua of the stroma of the glands 
of the adenomyoma, in the uterine horn on the opposite side from 
tubal pregnancy, is in itself strong presumptive evidence that these 
glands are derivatives of the uterine mucosa. 

Gyn, No. 12,380. Path. No. 9281. 

Subperitoneal and interstitial uterine 
myomata; gland hypertrophy of the endome- 
trium with extension of the uterine glands 
into the depth. Pregnancy in the left Fal- 
lopian tube (Fig. 66) . Diffuse adenomyoma in 
the right uterine horn with decidual cell 
formation in the stroma of the adenomyo- 
matous area. 

E. P., aged thirty, colored. Admitted September 19; discharged 
October 26, 1905. Complaint : uterine hemorrhage, pain in the back 
and right side for seventeen days. Her menses began without dis- 
turbance at fifteen and were regular for two years. The periods 
were at first painless. At present the flow usually lasts from six 
to eight days. Her last period occurred on August 24th and the 
previous one in July. 

The patient has been married fourteen years and has had no 

* Cullen, Thomas S.: The Velvety Feel of an Unruptured Tubal Pregnancy. 
Johns Hopkins Hospital Bulletin, 1906, p. 154. 

246 



DECIDUA IN ADENOMYOMA OF THE UTERINE HORN 



247 



children. There was a miscarriage at the second month four years 
ago. 

On examination under anaesthesia I made out definite myo- 
matous nodules in the uterus and on the left side a thickening differ- 
ing materially from the nodules in the uterus. The nodule on the 




Fig. 66. — Left tubal pkegnancy; discrete uterine myomata; adenomyoma of the 

RIGHT uterine HORN WITH DECIDUAL FORMATION IN THE .STROMA .SURROUNDING THE 

GLANDS, (i natural size.) 

Gyn. No. 12,380. Gyn.-Path. 9281. The uterus is occupied by several 
small subperitoneal and interstitial myomata. The left tube contains an unruptured pregnancy 
(a). The surface of the tube is covered with markedly dilated blood-vessels. In the right uterine 
horn are two small nodular thickenings which encroach upon the tube. Histological examination 
showed that they were adenomyomata. The stroma arountl many of the glands had been con- 
verted into typical decidua. 



left side on gentle palpation gave the impression of being rather soft, 
but on firm pressure was found to be hard. In other words, it had 
a velvety feel. On account of this peculiar sensation imparted to 
the examining finger I made a diagnosis of tubal pregnancy in 
addition to uterine myomata. 

Operation . — Hystero-myomectomy, double salpingectomy. 



248 ADENOMYOMA OF THE UTERUS / 

The left tube had not yet ruptured. The patient made a satis- 
factory recovery. 

Path. No. 9281 . — The specimen consists of a myo- 
matous uterus and of the tulles. The uterus is approximately 10 cm. 
in breadth, 10 cm. in length, and 7 cm. in its antero-posterior diam- 
eter (Fig. 66). Projecting from the surface are several myomatous 
nodules. The largest is 3.5 cm. in diameter. Scattered throughout 
the uterine walls are several smaller nodules. Covering the surface 
of the uterus posteriorly are numerous adhesions. The uterine 
cavity is 6 cm. in length. The mucosa is thickened, in places reach- 
ing 5 mm. 

In the right uterine horn is a nodular thickening 2.5 cm. in di- 
ameter. This is at the seat of the tubal attachment. The outer 
end of the tube is free from adhesions. 

On the left side of the uterus is a globular thickening, 4 cm. in 
diameter. It is smooth and covered over with dilated vessels. The 
central portion is filled with blood and placental tissue. The fim- 
briated end of the tube is intact. 

Histological Examination . — Sections from the 
endometrium show typical gland hypertrophy. There is little evi- 
dence of decidual formation. Here and there the glands extend a 
short distance into the muscle. Sections from the right cornu show 
diffuse myomatous thickening. We have in many places glands 
lying in direct contact with the muscle. The gland epithelium is 
cylindrical and here and there, where dilatation has taken place, the 
cells are flattened or are almost round. The gland cavities contain 
desquamated epithelium, a few polymorphonuclear leucocytes, 
some blood, and coagulated serum. At other points the glands show 
budding, and in numerous places there is a typical gland hyper- 
trophy. This gland hypertrophy is especially noticeable where the 
glands are surrounded by the characteristic stroma of the mucosa. 
These places show a most instructive picture. The stroma 
cells are swollen and have undergone typical 
decidual cell formation. Between these decidual 
cells are a good many small round cells and here and there a few poly- 



/ DECIDUA IN ADENOMYOMA OF THE UTERINE HORN 249 

morphonuclear leucocytes. The gland epithelium at such points is 
also cuboidal or flat. We also have stems of stroma projecting 
into some of the glands. These stems are covered over by one layer 
of epithelium, and the stroma cells are so swollen that they might 
very readily be mistaken for placental tissue. Some of the glands 
are gathered in groups and are surrounded by parallel and circular 
layers of muscle fibres. 

The left tube is the seat of a typical tubal pregnancy. 

Diagnosis . — Subperitoneal and interstitial uterine myo- 
mata; pregnancy in the left Fallopian tube; diffuse adenomyoma 
in the right uterine horn, showing decidual formation and also 
gland hypertroph}'. 

This is a most instructive case. We have in many instances 
been able to trace the extension of the gland elements in the adeno- 
myoma from the uterine mucosa. In this case we have an adeno- 
myoma of the uterine horn and the stroma elements surrounding 
the glands have taken on a sympathetic decidual development, just 
exactly as does the uterine mucosa at times when tubal pregnancy 
exists. This is another point convincing us that even where we 
are unable to trace the direct continuity between the uterine mucosa 
and the gland elements in an adenomyoma they are in all probal^ility 
derived from the same source, because they react in precisely the 
same manner as does the normal uterine mucosa; and, furthermore, 
they pour out their quota of menstrual blood at the period, as is 
evidenced by the fact that man}^ of the glands are filled and mark- 
edly dilated with blood either recent or old. 



\ 



CHAPTER XXIV 
ADENOMYOMA OF THE ROUND LIGAMENT 

Tumors of this character are comparatively rare, and until the 
publication of our case in May, 1896, this pathological condition 
seems to have been unknown. Similar cases have since been report- 
ed by Pfannenstiel,^ Blumer,- Bluhm,^ Meyer,* Aschoff,^ and others. 
Such a growth may vary from 1 to 2 or 3 cm. in diameter and is 
usually situated near the external inguinal ring. It consists of a 
very firm nodule, coarse in texture and intimately blended with the 
surrounding adipose tissue. On section it usually presents the pic- 
ture of a diffuse myoma, and the fibres can be seen spreading out 
into the adjoining tissue (Fig. 67, p. 256). Scattered throughout 
this coarse tissue are cyst-like spaces varying from a pinhead to 
several millimetres in diameter. They may be irregularly oval or 
slit-like. Their inner surfaces are smooth and their cavities usually 
contain chocolate-colored contents. Yellowish or brownish pig- 
mented areas are also frequently noted. 

On histological examination the framework of these growths is 
found to be composed of non-striped muscle fibres forming a dense 
irregular network and ver^^ suggestive of the diffuse myomata of 
the uterus. Occasionally, however, as in Aschoff's case, the major 
portion of the growth may consist of fibrous tissue. Scattered 

* Pfannenstiel: Ueber die Adenome des Genitalstranges. Verhandlungen der 
Deutschen Gesellschaft fiir Gyn., 1897. 

- Blumer: A Case of Adenomyoma of the Round Ligament. American Journal 
of Obstetrics, 1898, xxxvii, p. 37. 

^ Bluhm, Agnes: Zur Pathologie des Ligamentum Rotundum Uteri. Arch, 
f. Gynaek., 1898, Iv, S. 647. 

* Meyer: Ueber Driisen, Cysten, und Adenome im Myometrium der Erwach- 
senen. Ztschr. f. Geb. Gyn., 1900, xliii, S. 329. 

^ Aschoff, L. : Cystisches Adenofibrom der Leistengegend. Monatschr. f. 
Geburtshiilfe und Gynaekologie, 1899, ix, S. 25. 

250 



ADENOMYOMATA OF THE ROUND LIGAMENT 251 

throughout the diffuse myoma are islands of glands, round on cross- 
section (Fig. 68, p. 257), or irregular in form. They are lined with 
one layer of cylindrical, ciliated epithelium and the gland cavities 
are frequently filled with blood. These glands are surrounded by a 
stroma identical with that of the uterine mucosa. The gland 
epithelium and also the stroma cells often contain yellowish or brown 
granular pigment. The cyst-like spaces, noted macroscopically, 
are likewise lined with a single layer of cylindrical ciliated epithelium 
and the chocolate-colored contents are the remnants of old hemor- 
rhages. All of the adenomyomata so far reported have the same 
general characteristics. In our case^ nodules were found, both in 
the right and in the left round ligaments. 

Pfannenstiel found such a growth in the right inguinal region, 
and in the same case a second in the vaginal vault. In Blumer's 
case there were primarily two distinct nodules in the right groin, 
each about 6 mm. in diameter. These had gradual^ coalesced, and 
at the expiration of twenty-three years formed a nodule the size of 
a hen's egg. In Aschoff's case the nodule was situated in the left 
labium ma jus, and when first observed was no larger than a pea. 
It gradually became as large as an alniond, and at one point was in 
close proximity to the skin. Bluhm's patient had a firm elastic 
tumor the size of a plum and situated at the internal inguinal ring. 
As was noted in Pfannenstiel' s case, besides the nodule in the in- 
guinal region, there was a second, similar in character, situated in 
the vaginal vault. Cases of this character have also been reported 
by von HerfT^ and Pick.^ In Pick's case the myoma was as large 
as a hazelnut and situated in the posterior vaginal vault. 

The foregoing cases are definite examples of adenomyomata, 

* Cullen, Thomas S.: Adenomyoma of the Round Ligament. Johns Hopkins 
Hospital Bulletin, May, 1896; Further Remarks on Adenomyoma of the Round 
Ligament. Johns Hopkins Hospital Bulletin, 1898. 

^ Von Herff: Ueber Cystomyome und Adenomyome der Scheide. Verhand- 
lungen der Deutschen Gesellsch. f. Gyn., 1897. 

^ Pick, Ludwig: Die Adenomyome der Leistengegend und des hinteren Schei- 
dengewolbes; ihre Stellung zu den paroophoralen Adenomyomen der Uterus und 
Tubenwandung, v. Recklinghausen's Arch. f. Gynaek., Bd. Ivii, 461. 



252 ADENOMYOMA OF THE UTERUS 

and, as noted, the tumor ma}' be situated in one or both round liga- 
ments, in the labium ma jus or in the posterior vaginal vault; or 
such growths may occur simultaneously in the inguinal region and 
vaginal vault. 

Clinical History . — These nodules are usually of slow 
growth. In our own case it had been present eight years ; in Blumer's 
case for twenty-three years. The tumors may appear as early as 
the twentieth year, as in Blumer's case, or as late as the forty-second 
year, as noted in Aschoff's case. They are most common during the 
child-bearing period. The tumor at first causes little annoyance, 
but with its increase in size there is pain on walking, probably on 
account of the intimate association of the tumor with the surround- 
ing structures, as well as considerable distress on menstruation. At 
the period the lump may be increased in size and become very pain- 
ful, again diminishing in size after the flow is over. 

Prognosis . — Our case was of eight years' duration, and 
on histological examination gave no sign of malignancy, proving 
that the growth was benign in character. Blumer's case is even 
more convincing, as it had been under observation twenty-three years, 
the growth in that time not becoming larger than a hen's egg. 
Microscopic examination also showed its harmless character. 

Treatment . — Excision of the nodule is indicated solely 
on account of the discomfort produced by its presence. 

ORIGIN OF ADENOMYOMATA OF THE ROUND LIGAMENT 

As in the case of adenomyomata of the uterus, controversy has 
arisen as to whether the growths are derivatives of the Wolffian or 
of the Miillerian duct. Many authors claim that portions of the 
Wolffian duct have been nipped ofT during the development of the 
embr}^o and have been carried down the round ligament, and that in 
after-life they develop. They base their assumption on the fact that 
the Wolffian duct comes in close contact with the round ligament 
prior to its descent to the inguinal region. They also think that the 
gland elements of the adenomyoma bear some resemblance to por- 
tions of the Wolffian duct. Those dissenting from this view hold 



ADENOMYOMATA OF THE ROUND LIGAMENT 253 

that there is strong evidence that misplaced portions of Miiller's 
duct are responsible for the growth of these tumors. As has been 
noted, the glands in these adenomyomata cannot be distinguished 
in many instances from normal uterine glands. They are small, 
round, and lined with cylindrical ciliated epithelium. Furthermore, 
they are surrounded by the characteristic stroma of the normal 
uterine mucosa. Clinically, it has been noted that these growths 
may have a sympathetic relationship with the menstrual period, as 
seen in their increase in size at that time, followed in the intermen- 
strual period by a diminution in their volume. This increase in 
size is undoubtedly due to the hemorrhage into the glands at the 
periods, as is proved by the hemorrhagic contents at operation. In 
our case menstruation had commenced on May 18th and ceased on 
May 23d or just three days before operation; and on making sections 
the glands were found filled with well preserved blood. A further 
point in favor of the Miiller's duct origin is that these adenomyomata 
resemble in every particular the diffuse adenomyomata of the uterus, 
in which the glands are seen to be direct derivatives of the uterine 
mucosa. As was said when discussing the origin of adenomyomata 
of the uterus, there is no other place in the body in which mucosa 
similar to normal uterine mucosa is found, and furthermore no other 
mucous membrane that periodically discharges blood. These round 
ligament adenomyomata fulfil every requirement of normal uterine 
mucosa. It would be unwise to say absolutely that these growths 
cannot possibly be derived from remains of the Wolffian duct, but 
the evidence is overwhelmingly in favor of the Miiller's duct origin. 
Before concluding a consideration of these cases we must briefly 
refer to the case reported by Martin^ in 1891. A patient aged 
seventy consulted him about a rapidly growing tumor. He opened 
the abdomen and removed 12 litres of chocolate-colored fluid from a 
tumor springing from the left round ligament. This was attached 
to the ligament by a definite pedicle. Pommorsky, who made the 
microscopic examination, found that the cyst containing the choco- 

^ Martin A.: Zur Pathologie des Ligamentum rotundum. Ztschr. f. Geb. u. 
Gyn., Bd. xxii, S. 444. 



254 ADENOMYOMA OF THE UTERUS 

late-colored fluid had very thin walls, and that its inner surface was 
in places covered b\^ clots. The pedicle of the tumor contained 
several small cysts which were filled with clear fluid and which com- 
municated with one another. One of these cysts was lined with 
low cylindrical ciliated epithelium. It is quite probable that this 
was an adenomyoma of the round ligament situated nearer the 
uterine horn than usual. I noted in speaking of adenomyoma of 
the uterus that when the tumor became intraligamentarj^, as in the 
case represented in Fig. 43 (p. 151) , or in those of Breus and Kroenig, 
large cysts developed. These were filled with chocolate-colored 
fluid and at some points small cysts were still visible. In adeno- 
myoma of the round ligament situated in the inguinal region or in 
the labium ma jus, we have a continual surrounding pressure, as in 
the uterus. In Martin's case, on the other hand, there was nothing 
to prevent cystic formation. The process appears to be analogous 
to the cystic development occurring in subperitoneal or intraliga- 
mentar}^ adenomyomata of the uterus. 

ADENOMYOMATA OCCURRING IN BOTH THE RIGHT AND LEFT ROUND 
LIGAMENT IN THE SAME INDIVIDUAL (Figs. 67 and 68) 

Gyn. No. 3891. 

L. N., aged thirty-seven. Admitted October 18, 1895. The 
patient has been married thirteen years and had one instrumental 
labor seven years ago. Her menses commenced at fourteen and 
were regular until the birth of the child, since which time they have 
occurred every three weeks, have been very copious, and have lasted 
from four to five days. The latter part of each period has been ac- 
companied by a good deal of pain, which persists for several days 
after the flow. The last menstrual period occurred two weeks be- 
fore admission. About eight years ago the patient noticed a slight 
swelling in the right inguinal region. This has gradually enlarged, 
more especially during the last two years. She has had severe cut- 
ting pain in the nodule and radiating to the back. This has been 
most severe after exertion or during the menstrual period. The 
patient is much debilitated. The vaginal examination is negative. 



ADENOMYOMATA OF THE ROUND LIGAMENT 255 

The mass occupies the upper part of the right labium, is irregularly 
ovoid and firmly fixed in the deeper tissues. It is, however, movable 
to the extent of one centimetre. 

October 19th: An oval incision was made over the site of the 
nodule. The mass was freed laterally and posteriorly. Above it 
was closely connected with a band of tissue, 1 cm. broad. This 
proved to be the right round ligament. The round ligament was 
traced upward to the internal ring, and midway between the external 
and internal ring it contained a nodule, 1 by .6 cm. The round liga- 
ment was pulled down, clamped, and cut off at the internal ring. 
Several enlarged lymph-glands were then dissected out. The pillars 
of the ring were brought together with silver wire and the round liga- 
ment was sutured into the canal. The patient was discharged on 
November 3, 1895. 

Gyn.-Path. No. 926. 

The specimen consists of a piece of tissue measuring 7 by 4 by 
3.5 cm. One surface of this is covered with normal skin. The under- 
lying tissue is composed of fat, embedded in which is an exceedingly 
firm nodule, measuring 3.5 by 3 by 2 cm. (Fig. 67). This nodule on 
section is composed of interlacing bundles of fibres which form a 
dense network. Scattered throughout the nodule are many small, 
irregular, pale, translucent, homogeneous areas. On examining 
the specimen after hardening in Miiller's fluid some of the homo- 
geneous areas are found to contain round, oval, or irregular spaces. 

Histological Examination . — The nodule is to a 
great extent composed of non-striped muscle fibres which wind in 
and out in all directions, but do not show any concentric arrange- 
ment. In many places the muscle fibres are swollen and the cell 
protoplasm contains large quantities of yellowish-brown granular 
pigment. At several points the muscle has undergone hyaline de- 
generation. This is especially noticeable around blood-vessels. 
The blood-supply is abundant. Scattered here and there throughout 
the muscle substance are small islands of adipose tissue. Travers- 
ing the nodule in all directions are glands (Fig. 68). Some of these 



256 ADENOMYOMA OF THE UTERUS 

are small and round on cross-section; the others are cut lengthwise. 
These glands are surrounded by stroma similar to that of the uterine 
mucosa. It would be impossible to distinguish some of these from 
uterine glands. A few of the glands present slight dichotomous 
branching. Some of them contain round masses of protoplasm, 
scattered throughout which are several nuclei. These giant cells 
appear to be cross-sections of tufts of epithelium. In many places 
the glands present a peculiar arrangement and correspond to von 
Recklinghausen's pseudo-glomeruli, which consist of stroma re- 
sembling that of the uterine mucosa. They contain numerous 




Fig. 67. — Adeno.myoma of the round ligament. (Natural size.) 

Gyn.-Path. No. 9 2 8. The figure represents a longitudinal section of the tissue 
removed. The greater part consists of fat and the surface is covered with skin. Occupying 
the lower part is an oval area, dark in color and composed of fibres running in all directions — 
the myoma. Passing off from it are numerous strands which merge into the adipose tissue. 
The small dark areas in the myoma represent dilated gland cavities. The large and small 
dark masses in the adipose tissue are hemorrhages. For the histological picture of the adeno- 
myoma see Fig. 68. 

capillaries and may have one or more glands situated in their depth. 
In some places there has been hemorrhage into their stroma. The 
pseudo-glomeruli are half-moon-shaped, cone-shaped, or irregular 
in contour. They are covered with one layer of cylindrical ciliated 
epithelium. What corresponds to Bowman's capsule consists of a 
layer of cells resting directly upon the muscle fibres. The cells of 
the capsule opposite the convexity of the glomerulus are almost 
flat. On passing off laterally they are seen to be cuboidal or cylin- 
drical. The cells of the so-called capsule are directly continuous 
with those of the pseudo-glomerulus. The space between the cap- 



>f.^.? 



ADENOMYOMATA OF THE ROUND LIGAMENT 



257 



sule and the glomerulus may be empty. Many, however, contain 
desquamated epithelial cells, some of which are vacuolated and have 
brown, granular pigment in their interior. Numerous spaces con- 
tain blood-corpuscles. On tracing one of the spaces laterally it is 
found to be directly continuous with the lumen of a gland. The 
<?apsule forms one wall of the gland and the pseudo-glomerulus, the 
other (Fig. 68). In other words, the space between the capsule and 
the so-called glomerulus is nothing more than a dilatation of the 




Fig. 68. — Adenomyoma of the Round Lig.\ment. (20 diameters.) 

Gyn.-Path. No. 928. The section is taken from the oval nodule in Fig. 67. 
The framework consists of non-striped muscle fibres cut chiefly longitudinally. Scattered 
throughout the muscle are glands which occur singly or in groups. They are round, oval or 
irregular and show some branching. All are lined with one layer of cylindrical epithelium and 
even the smaller ones are surrounded by a definite stroma which with the high power is seen 
to be identical with that of the uterine mucosa. In the right lower corner is adipose tissue. 
A few stray fat cells are found in the myoma. In the left upper corner is a so-called pseudo- 
glomerulus. 

gland cavity or of a miniature uterine cavity. In numerous places 
the gland epithelium on one side is found to be cylindrical; on the 
other side, cuboidal or almost flat. On examining these more closely 
it is found that where the epithelium is separated from the muscle 
by a moderate amount of stroma it is cylindrical, but where the 
epithelium rests directly upon the muscle, it is invariably cuboidal 
or flat. A few small glands are seen lying directly between muscle 
bundles. 

17 



258 ADENOMYOMA OF THE UTERUS 

Extending into the myomatous growth from the peripherj^ are 
numerous bands of connective tissue. The adipose tissue surround- 
ing the myoma shows considerable hemorrhage. The skin cover- 
ing the surface of the specimen is normal. Unfortunatel}^ we were 
not able to obtain the smaller nodule of the round ligament for ex- 
amination and cannot say whether it was an adenomyoma or not. 

The patient was readmitted on May 25, 1897. Shortly after 
the previous operation she noticed a swelling in the opposite (left) in- 
guinal region immediately above the pubes. This has graduallj^ 
increased in size and is quite painful. The menstrual period has 
not been regular, occurring at intervals of from three to five weeks. 
The last menstruation commenced May 18th and ceased May 23d. 
On May 26th I removed the nodule with little difficulty and found 
that it was directly continuous with the left round ligament. 

G y n . - P a t h . No. 1741 . — The specimen consists of an 
irregular mass, approximately 3 cm. in its various diameters. It 
comprises a firm central portion, 1.5 cm. in diameter, and is sur- 
rounded on all sides by adipose tissue. Traversing the central por- 
tion are numerous delicate fibres and at several points are brown or 
yellow homogeneous areas. Several pin-point cavities are demon- 
strable. At one point is a semicircular slit, 2 mm. long, and in the 
immediate vicinity an irregular cavity averaging 3 mm. in diameter. 
The walls of this cavity are rather uneven and are slightly granular. 

Histological Examination . — The adipose tissue 
in the outlying portions is comparatively normal, but as one ap- 
proaches the firm nodule the blood-vessels increase in number and 
size. Young capillaries are found w^andering in between the fat cells, 
the fat cells becoming gradually separated from one another. At 
the margin of the firm nodule the growth is composed almost ex- 
clusively of connective tissue. Here and there this connective 
tissue encircles round or oval clumps of cells having oval, some- 
what deeply staining nuclei. Scattered between these are a few 
small round cells and occasionally polymorphonuclear leucocytes. 
Such areas are very striking on account of their richness in nuclei. 



ADENOMYOMATA OF THE ROUND LIGAMENT 259 

in contrast to the surrounding tissue, which is poor in cell elements. 
The cellular areas resemble closely the stroma of the uterine mucosa. 
On passing toward the centre of the nodule similar areas are found 
containing one or more glands lying in their centre or at the peri- 
phery. These glands, according to the angle at which they have 
been cut, are round, elongate, or slightly branching. Their epithe- 
lium is cylindrical, apparentl}^ ciliated, and their nuclei are oval and 
situated at some distance from the bases of the cells. In short, these 
glands cannot be distinguished from uterine glands. The majority 
of the gland cavities are completely filled with blood and desquamated 
epithelial cells. The stroma of the central portion of the nodule is 
composed almost entirely of non-striped muscle fibres, and here 
the glands are abundant and present a more complicated picture. 
They are branching, form narrow channels and little bays, and 
in places can be traced in their continuity for at least 4 mm. On 
one side of the gland there is usually a considerable amount of stroma 
separating the epithelium from the undertying muscle. At such 
points the epithelium is cylindrical, but on the opposite side, where 
the cells rest directly on the muscle, it is frequently flattened. There 
are a few areas corresponding to von Recklinghausen's pseudo- 
glomeruli. Some of these contain glands, others do not. 

The nodules in both round ligaments are typical adenomyomata. 



SUMMARY 

In cases of adenomyoma of the uterus we usually find a diffuse 
myomatous thickening of the uterine muscle. This thickening may 
be confined to the inner layers of the anterior, posterior, or lateral 
walls, but in other cases the myomatous tissue completely encircles 
the uterine cavity. 

This diffuse myomatous tissue contains large or small chinks, and 
into these chinks the normal uterine mucosa flows. If the chinks 
are small, there is only room for isolated glands, but where the 
spaces are of goodly size large masses of mucosa flow into and fill 
them. We accordingly have a diffuse myomatous growth with 
normal mucosa flowing in all directions through it. The mucosa 
lining the uterine cavity is perfectly normal. 

After a time portions of the diffuse myoma may be nipped off 
and are carried toward either the outer or inner surfaces of the uterus. 
If they become submucous growths, they are gradually expelled. 
If the}^ pass toward the outer surface, they become either subperi- 
toneal or intraligamentar}\ We have accordingly divided adeno- 
myomata into the following groups: 

1. Adenomyomata in which the uterus preserves a relatively 
normal contour. 

2. Subperitoneal or intraligamentary adenomyomata. 

3. Submucous adenomyomata. 

A diffuse adenomyoma presents a very coarse appearance, owing 
to the fact that the myomatous muscle bundles run in all directions. 
In the spaces between bundles and occasionally surrounded by cir- 
cular rings of muscle we find spaces filled with translucent and slightly 
punctiform tissue — areas of uterine mucosa. Sometimes its direct 
connection with the mucosa of the uterine cavity can be traced. 
Often are noted cyst-like spaces scattered throughout the diffuse 
myoma. These are filled with a chocolate-colored fluid and are lined 

260 



SUMMARY 261 

with a definite membrane, often 1 to 2 mm. thick. They are mini- 
ature uterine cavities and the chocolate-colored fluid is old men- 
strual blood that could not escape. 

When an adenomyomatous nodule becomes subperitoneal, the 
menstrual flow in the growth may gain the upper hand and the 
myoma become cystic, the contents, of course, being formed from 
the accumulation of old menstrual blood. 

Symptoms .* — Our youngest patient was nineteen, our 
oldest sixty. The disease is most prevalent between the thirtieth 
and sixtieth years; it does not in any way tend to sterilit3\ 

Lengthened menstrual periods are the first symptom. The 
flow gradually assumes the proportions of hemorrhages and event- 
ually the period may become continuous. 

At the period there is often discomfort, and occasionally a grind- 
ing pain in the uterus, evidently due to the increased tension, since 
all the islands of mucosa scattered throughout the diffuse myoma 
naturally swell up at the menstrual period, and thus increase the 
size of the organ. 

In over two-thirds of our cases there was no intermenstrual dis- 
charge. This is perfectly natural, as in these cases the uterine 
mucosa is normal and no disintegration of tissue is going on. 

Clinically the diagnosis of diffuse adenomyoma is rela- 
tively easy, for the following reasons : 

1. The bleeding is usually confined to the period. 

2. There is usually much pain, referred to the uterus, at the 
period. 

* While von Recklinghausen was carrying on his work on the pathology of 
adenomyoma W. A. Freund was carefully analyzing the sj'mptomatology in such 
cases to determine, if possible, whether the clinical picture was sufficiently charac- 
teristic to enable the surgeon to make a diagnosis before operation. In contrast 
with his findings, our experience goes to show that neither an infantile condition of 
the uterus nor sterility is in any sense a prominent feature. 

Von Rosthorn (Med. Klin. Berlin, 1905, I, 201-203), in a recent publication, 
reports two cases, in one of which the clinical picture before operation strongly sug- 
gested diffuse adenomyoma. He says that in the future, with our increased knowl- 
edge, a provisional diagnosis of adenomyoma is sometimes possible Ijefore operation. 



262 ADENOMYOMA OF THE UTERUS 

3. There is usually no intermenstrual discharge of any kind. 

4. The uterine mucosa is perfecij^y normal and may be rather 
thick. 

No other pathological condition of the uterus, as a rule, gives this 
characteristic picture. 

Treatment . — The patient's health is often gradually under- 
mined by the uterine hemorrhages, and the only way to control them 
is to remove the uterus. A supravaginal hysterectomy is all that is 
necessary. The ovaries should be saved. 

The prognosis is good, as the glands of the adeno- 
myoma are perfectly normal uterine glands and are surrounded by 
the characteristic stroma of the mucosa. 

Origin . — The glands in the adenomyoma originate, in the 
vast majority of the cases at least, from the uterine mucosa. The 
reader will be thoroughly convinced of this after studying the vari- 
ous histological pictures in the book. 

Cause . — The cause of adenomyoma is still unsolved. 



INDEX OF CASES ARRANGED ACCORDING TO THEIR 
GYNECOLOGICAL NUiWBERS 



Cases Observed in the Johns Hopkins Hospital 



PAGE 

Gvn. No. 2573 17 

Gyn. No. 2699 93 

Gyn. No. 2706 29 

Gyn. No. 2744 64 

Gyn. No. 2754 42 

Gyn. No. 2806 '47 

Gyn. No. 3126 213 

Gyn. No. 3136 75 

Gyn. No. 3192 . .. 52 

Gyn. No. 3204 50 

Gyn. No. 3293 132 

Gyn. No. 3379 245 

Gyn. No. 3395 240 

Gyn. No. 3399 244 

Gyn. No. 3401 241 

Gyn. No. 3418 8 

Gyn. No. 3600 188 

Gyn. No. 3614 23 

Gyn. No. 3715 240 

Gyn. No. 3805 240 

Gyn. No. 3809 31 

Gyn. No. 3891 254 

Gyn. No. 3898 166 

Gyn. No. 4364 97 

Gyn. No. 4415 190 

Gyn. No. 5768 54 

Gyn. No. 5782 218 

Gyn. No. 5973 158 

Gyn. No. 6083 68 

Gyn. No. 6240 200 

Gyn. No. 6635 239 

Gyn. No. 6855 160 

Gyn. No. 6855 149 

Gyn. No. 7011 108 

Gyn. No. 7153 34 

Gyn. No. 7569 88 

Gyn. No. 7859 109 

Gyn. No. 8438 223 

Gyn. No. 8647 128 

Gyn. No. 8780 149 

Gyn. No. 9024 138 

Gyn. No. 9069 33 

Gyn. No. 9457 60 

Gyn. No. 9637 139 

Gyn. No. 9788 85 

Gyn. No. 9971 209 

Gyn. No. 10314 161 



PAGE 

Gyn. No. 10516 203 

Gyn. No. 10519 86 

Gyn. No. 10872 163 

Gyn. No. 11120 100 

Gyn. No. 11252 114 

Gyn. No. 11363 106 

Gyn. No. 11572 238 

Gyn. No. 118.50 16 

Gyn. No. 12036 145 

Gyn. No. 12060 212 

Gyn. No. 12080 45 

Gyn. No. 12221 232 

Gyn. No. 12304 213 

Gyn. No. 12358 117 

Gyn. No. 12380 246 

Gyn. No. 12585 140 

Gyn. No. 12599 22 

Gyn. No. 12678 104 

Gyn. No. 12681 14 

Gyn. No. 12807 82 

Gyn. No. 12841 83 

Gyn. No. 12918 206 

Gyn. No. 12944 95 



San. No. 469 

San. No. 1453 

San. No. 1552 

San. No. 1847 

San. No. 1852 

San. No. 1872 j- Howard A. Kellv. 

San. No. 1913 

San. No. 1931 

San. No. 1944 

San. No. 2144 

San. No. 2178 



I 



62 
115 
105 
230 
225 
140 
122 

20 
123 

40 
103 



Church Home and Infirmary. 

Case No (G. L. Hunner) 99 

Case No. 511.. (Thomas CuUen) 211 

Case No. 1019 . . (Thomas Cullen) 113 

Case No. 1517. . (Thomas Cullen) 242 

Dr. W. W. Russell's patient 67 

Emergency Hospital, Frederick, Md. 

(Thomas Cullen) 119 

Dr. Joseph Price's case 228 



263 



INDEX OF GYNECOLOGICAL-PATHOLOGICAL 

NUMBERS 



Gyn.-Path. No. 163 17 

Gyn.-Path. No. 245 29 

Gyn.-Path. No. 246 93 

Gyn.-Path. No. 274 64 

Gyn.-Path. No. 290 42 

Gyn.-Path. No. 334 47 

Gyn.-Path. No. 493 213 

Gyn.-Path. No. 497 75 

Gyn.-Path. No. 525 52 

Gyn.-Path. No. 526 50 

Gyn.-Path. No. 583 132 

Gyn.-Path. No. 633 245 

Gyn.-Path. No. 645 244 

Gyn.-Path. No. 647 241 

Gyn.-Path. No. 649 240 

Gyn.-Path. No. 659 178 

Gyn.-Path. No. 661 8 

Gyn.-Path. No. 777 188 

Gyn.-Path. No. 788 23 

Gyn.-Path. No. 843 240 

Gyn.-Path. No. 881 31 

Gyn.-Path. No. 892 240 

Gyn.-Path. No. 928 255 

Gyn.-Path. No. 934 166 

Gyn.-Path. No. 1170 97 

Gyn.-Path. No. 1207 190 

Gyn.-Path. No. 1741 258 

Gyn.-Path. No. 1758 62 

Gyn.-Path. No. 2066 54 

Gyn.-Path. No. 2048 179 

Gyn.-Path. No. 2075 218 

Gyn.-Path. No. 2084 218 

Gyn.-Path. No. 2250 158 

Gyn.-Path. No. 2356 68 

Gyn.-Path. No. 2532 200 

Gyn.-Path. No. 2845 239 

Gyn.-Path. No. 3107 160 

Gyn.-Path. No. 3289 108 

Gyn.-Path. No. 3429 34 

Gyn.-Path. No. 3721 238 

Gyn.-Path. No. 3903 88 

Gyn.-Path. No. 4122 109 

Gyn.-Path. No. 4656 223 

Gyn.-Path. No. 4820 237 

Gyn.-Path. No. 4838 128 

Gyn.-Path. No. 4966 149 

Gyn.-Path. No. 5187 138 

Gyn.-Path. No. 5229 33 



PAGK 

Gyn.-Path. No. 5668 60 

Gyn.-Path. No. 5840 139 

Gyn.-Path. No. 6008 85 

Gyn.-Path. No. 6150 209 

Gyn.-Path. No. 6216 115 

Gyn.-Path. No. 6319 99 

Gyn.-Path. No. 6531 161 

Gyn.-Path. No. 6536 105 

Gyn.-Path. No. 6754 86 

Gyn.-Path. No. 6764 '203 

Gyn.-Path. No. 7026 181 

Gyn.-Path. No. 7076 163 

Gyn.-Path. No. 7351 100 

Gyn.-Path. No. 7507 1 14 

Gyn.-Path. No. 7593 106 

Gyn.-Path. No. 7800 238 

Gyn.-Path. No. 8197 16 

Gyn.-Path. No. 8346 230 

Gyn.-Path. No. 8347 225 

Gyn.-Path. No. 8393 119 

Gyn.-Path. No. 8426 211 

Gyn.-Path. No. 8433 140 

Gyn.-Path. No. 8579 145 

Gyn.-Path. No. 8602 212 

Gyn.-Path. No. 8641 122 

Gyn.-Path. No. 8715 45 

Gyn.-Path. No. 8760 40 

Gyn.-Path. No. 8807 123 

Gyn.-Path. No. 8832 232 

Gyn.-Path. No. 8890 213 

Gyn.-Path. No. 8983 117 

Gyn.-Path. No. 9281 246 

Gyn.-Path. No. 9312 .- 228 

Gyn.-Path. No. 9336 140 

Gyn.-Path. No. 9366 22 

Gyn.-Path. No. 9367 20 

Gyn.-Path. No. 9407 113 

Gyn.-Path. No. 9466 104 

Gyn.-Path. No. 9517 14 

Gyn.-Path. No. 9699 82 

Gyn.-Path. No. 9705 40 

Gyn.-Path. No. 9744 83 

Gyn.-Path. No. 9803 103 

Gyn.-Path. No. 9841 206 

Gyn.-Path. No. 98.58 67 

Gyn.-Path. No. 9970 95 

Gyn.-Path. No. 10771 176 

Gyn.-Path. No. 10669 242 



265 



INDEX 



Abortion and adenomyoma. differentiation. 

183 
Abscess, in uterine cornu, 244 

miliary, of ovary, 240 

tubo-ovarian, 47 
Adenocarcinoma, and adenomyoma occurring 
independently in same uterus, 218 

developing from adenomyoma, 222 
cases of, 223 
Adenocystoma of ovary, 97 
Adenomyoma, 1 

adenocarcinoma developing from, 222 
cases of, 223 

and abortion, differentiation, 183 

and adenocarcinoma occurring independently 
in same uterus, 218 

and carcinoma, differentiation, 175, 185 

and chorioepithelioma. differentiation, 183 

and endometritis, differentiation, 184 

and large and dilated uterine glands with 
overgrowth of stroma of mucosa, differen- 
tiation, 180 

and myoma, differentiation, 182 

and polypi, differentiation, 178 

and proliferation of stroma of uterine mucosa 
associated with copious uterine hemor- 
rhages, differentiation, 180 

and salpingitis, differentiation, 184 

and sarcoma, differentiation, 183 

and tubal pregnancy, differentiation, 184 

and venous sinuses in uterine mucosa, differ- 
entiation, 179 

arising from uterine portion of uterine horn, 
235 

benign character of, cases illustrating, 188 

cases of diffuse, 8 

causes of, 199, 262 

cervical, 165 

clinical picture in, 173 

commencing, 20, 29, 31, 33, 50, 52, 67, 83 

condition of tubes and ovaries in, 171 

diagnosis of. 175,261 
differential, 177 

diffuse, cases of, 8 

and squamous-cell cancer of cervix, 206 
hypertrophy of cervix and, 200 

267 



Adenomyoma, diffuse, of uterine horn, 235, 246 
origin of, 193 
prognosis in, 187, 262 
symptoms of, 173, 261 
treatment of, 186, 261 
discharge in, 173 
discrete, 60, 140 

in left uterine horn, 100 
of utero-ovarian ligament, 141 
from tubal portion of uterine horn, 236 
hemorrhage in, 173 
incidence of, 174 

in one horn of bicornate uterus, 203 
in right and left round ligament in same 

person, 254 

interstitial, 138 

intraligamentary, 145 

case of, 149 

cystic, 148 

of round ligament, 250 

origin of, 252 
of uterine horn, 29, 52, 67, 100, 117, 119, 
235, 237, 239, 240, 241, 242, 244, 245, 
246 
decidua developing in adenomyoma of, 
246 
origin of, 193 
pain in, 173 

physical examination in, 175 
prognosis in, 187 " 

relation of, to pregnancy, 174 
submucous, 156 

cases of, 149, 158, 160, 161, 163 
origin of, 195 
subperitoneal, 125 
cases of, 114,128 
cystic, 128 
origin of, 194 
summary of, 260 
treatment of, 186 

uterus preserving relatively normal contour, 2 
cases of, 8 
cystic glands in, 6 
cyst -like spaces in, 3 
dilated glands in, 6 
glands in, 4, 5, 7 



268 



INDEX 



Adenomyoma. uterus preserving relatively nor- 
mal contour, histological ap- 
j>earances. 5 
islands of glandular tissue in, 6 
thickening in, 2, 3 
uterine mucosa in, 5 
vaginal discharge in, 173 
Adhesions, pelvic. 31, 46, 50, 67, 82, 84, 97, 103, 

109. 138. 149, 245 
Age at which adenomyoma occurs. 174 
Atrophy of uterine mucosa, 133, 240, 241, 244 



BicoRNATE uterus, adenomyoma in one horn 
of, 203 



Canal, von Recklinghausen's, 7 
Carcinoma and adenomyoma, differentiation, 
175,185 
squamous-cell, of cervix, diffuse adenomy- 
oma of corpus, 206 
Cervical adenomyoma, 165 
Cervix, double, 161 

hypertrophy of, and diffuse adenomyoma, 

200 
squamous-cell cancer of, diffuse adenomy- 
oma of corpus, 206 
Choriospithelioma and adenomyoma, differ- 
entiation, 183 
Cyst, Graafian follicle, 82 

of ovary, 34, 50, 60, 82, 93, 97, 166, 238, 245 
tubo-ovarian, 29 
Cystadenoma of ovary, 97, 238 

with carcinomatous changes, 238 
Cystic adenomyoma, subperitoneal, 128, 132 
glands in adenomyoma in which uterus pre- 
serves relatively normal contour, 6 
intraligamentary adenomyoma, 148 
spaces in uterine horn, 119, 243 
Cyst-like spaces in adenomyoma in which 
uterus preserves relatively normal contour, 5 
Cysts, multiple, in subperitoneal myoma, 128. 
132 



Decidua developing in stroma of adenomyoma 

of uterine horn, 246 
Diagnosis, 175 
differential, 177 
from abortion, 183 
from cancer, 185 
from chorio-epithelioma, 183 
from endometritis, 184 
from large venous sinuses in the mucosa, 
179 



Diagnosis, differential, from marked prolifera- 
tion of the stroma of the mucosa, 180 
from myomata, 182 
from polypi. 178 

from salpingitis and endometritis, 184 
from sarcoma. 183 
from tubal pregnancy, 184 
from very large and dilated uterine glands 
with overgrowth of stroma of mucosa, 
180 
Dilated glands in adenomyoma in which uterus 

preserves relatively normal contour, 6 
Discharge in adenomyoma, 173 
Double cervix, 161 
vagina, 161 

Edema of uterine mucosa, 50, 128, 133 
Endometritis, and adenomyoma, differentiation, 
184 

chronic, 45 

slight, 22, 41, 117 

subacute, 64 
Endometrium, gland hypertrophy of, 140, 149, 

246. (See Mucosa.) 



Fallopian tube, left, pregnancy in, 246 
accessory ostium of, 241 
tubes, condition of, in adenomyoma, 171 



Gland hypertrophy of endometrium, 140, 149, 

246 
Gland-like spaces in uterine horn, 240, 241, 

244, 245 
Glands, cystic, in adenomyoma in which uterus 
preserves relatively normal contour, 6 
dilated, in adenomyoma in which uterus 

preserves relatively normal contour, 6 
in adenomyoma in which uterus preserves 

relatively normal contour, 4, 5, 7 
uterine, large and dilated, with overgrowth 
of stroma of mucosa, adenomyoma and. dif- 
ferentiation, 180 
Glandular tissue, islands of, in adenomyoma in 
which uterus preserves relatively normal 
contour, 6 
uterine polyp, 75,97, 178 
Graafian follicle cyst, 82 



Hauptkanal of von Recklinghausen, 7 
Hematosalpinx, 109 

Hemorrhage, into and thickening of uterine 
mucosa, 24 



INDEX 



269 



Hemorrhage from venous sinuses in uterine 
mucosa, adenomyoma and, differentiation, 
179 
in adenomyoma, 173 
Hydrosalpinx, 29, 166, 241 
Hypertrophy, gland, of endometrium, 140, 149, 
246 
of cervix and diffuse adenomyoma, 200 

Interstitial adenomyoma, 138 
Intraligamentary adenomyoma, 145 

case of, 149 

cystic, 148 



Ligament, round, adenomyoma of, 250 
origin, 252 
right and left, adenomyoma in, in same 
person, 254 
utero-ovarian, discrete adenomyoma of, 141 



Miliary abscesses of ovary, 240 
Miniature uterine cavities, 3. 69, 100, 141, 161 
Mucosa, uterine, atrophy of, 133, 240, 241, 244 
edema of, 50, 128, 133 
hemorrhage into and thickening of, 24 
hypertrophy of, 140, 149, 246 
in adenomyoma in which uterus preserves 

relatively normal contour, 6 
polypi of, 75, 97, 178 

stroma of, proliferation, associated with 
copious uterine hemorrhage, differentia- 
tion from adenomyoma, 180 
venous sinuses in, and adenomyoma, differ- 
entiation, 179 
Multiple cysts in subperitoneal myoma, 128, 132 
Myoma and adenomyoma, differentiation, 182 
Myomatous thickening, diffuse, but no glandular 
invasion of uterine walls, 230 



Ostium, accessory, of Fallopian tube, 241 
Ovary, adenocystoma of, 97,238 

condition of, in adenomyoma, 171 

cyst of, 34, 50, 60, 82, 93, 97, 166, 238, 245 
with carcinomatous changes, 238 

miliary abscesses of, 240 

papillocystoma of, 166 



Pain in adenomyoma, 173 

Papillocystoma of ovary, 166 

Pathological changes, multiple, in the pelvis. 

228 



Pelvic adhesions, 24, 31, 33, 34, 46, 47, 50, 64, 
67, 82, 84, 97, 103, 108, 109, 138, 149, 166, 
171, 240, 245 

Pelvis, pathological changes in, 228 

Physical examination in adenomyoma, 175 

Polyp, and adenomyoma, differentiation, 178 
glandular uterine, 75, 97 

Pregnancy, in left Fallopian tube, 246 
relation of adenomyoma to, 174 
tubal, and adenomyoma, differentiation, 184 

Proliferation of stroma of uterine mucosa asso- 
ciated with copious uterine hemorrhages, 
adenomyoma and, differentiation, 180 

Purulent salpingitis, acute, 46 



Round ligament, adenomyoma of, 250, 252 
right and left, adenomyoma in, in same 
person, 254 



Salpingitis, 84, 171 
acute purulent, 46 

and adenomyoma, differentiation, 184 
chronic, 46, 240, 244 
Sarcoma and adenomyoma, differentiation, 183 
Sinuses, venous, in uterine mucosa, and adeno- 
myoma, differentiation, 179 
Squamous-cell cancer of cervix, diffuse adeno- 
myoma of body, 206 
Stroma of uterine mucosa, proliferation of, as- 
sociated with copious uterine hemorrhages, 
adenomyoma and, differentiation, 180 
Submucous adenomyoma, 149, 156, 158, 160, 
161, 163 
cases of, 158 
origin of, 195 
Subperitoneal adenomyoma, 114, 125, 138, 139, 
140, 145 
cases of, 128 
cystic, 128, 132 
origin of, 194 
multiple cysts in, 128, 132 



Thickening, and hemorrhage from uterine mu- 
cosa, 24 
in adenomyoma in which uterus preserves 
relatively normal contour, 2, 3 
diffuse of uterine wall, but no glandular 
invasion, 14, 22, 64, 230 
Tubal iJortion of uterine horn, adenomyoma 
from, 236 
pregnancy and adenomyoma, differentiation, 
184 



270 



INDEX 



Tubes, condition of, in cases of adenomyoma, 

171 
Tubo-ovarian abscess, 47 

cyst, 29 



Uterine glands, large and dilated, with over- 
growth of uterine mucosa, adenomyoma 
and, differentiation, 180 
horn, abscess in, 244 

adenomyoma in, 29, 52, 67, 100, 117, 119, 

235, 237, 239, 240, 241, 242, 244, 245, 

246 
tubal portion of, adenomyoma from, 236 
uterine portion of, adenomyoma arising 

from, 235 
mucosa, atrophy of, 133, 240, 241, 244 
edema of, 50, 128, 133 
hemorrhage and thickening of, 24 
hypertrophy of, 140, 149, 246 
in adenomyoma in which uterus preserves 

relatively normal contour, 5 



Uterine mucosa, polypi of. 75, 97, 178 

stroma of, proliferation, associated with 
copious uterine hemorrhages, adenomy- 
oma and, differentiation, 180 
venous sinuses in, and adenomyoma, differ- 
entiation, 179 
I^olyp, 75, 97 
walls, adenomyoma of, 2, 

benign character, 188, 190 
myomatous thickening of, 14, 22, 23, 04, 
230 
Utero-ovarian ligament, discrete adenomyoma 

of, 141 
Uterus, bicornate, adenomyoma in one horn 
of, 203 



Vagina, double, 161 
Vaginal discharge in adenomyoma, 173 
Venous sinuses in uterine mucosa and aden- 
omyoma, differentiation, 179 
Von Recklinghausen's canal, 7 



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